Doctor's Office Visits & Medicare

If you are a Medicare patient, there are certain tests that Medicare will not cover and the doctor's office is required to notify you of this in writing BEFORE the test is performed. This form is called an ABN - advanced beneficiary notice. If you are not notified before the test is performed and Medicare denies payment as a non-covered service, you may NOT have to pay for it.

Below is the link that Centers for Medicare and Medicaid Services that provides a detailed explanation of the use of an ABN:

https://www.cms.gov/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf

Most lab tests are sent to an off site lab instead of being processed at the actual doctor's office, which means that the patient will probably receive an additional bill.

Another little known fact or benefit used by Medicare patients, is the free "Welcome to Medicare" preventative physical which must be used within the first 12 months of being on Medicare.
No deductible or copay is charged by Medicare if the visit is coded/billed correctly.  The correct procedure code that must be submitted in order for the visit to be paid is G0348.

However, in addition to the wellness exam, physician's routinely will charge an additional code if any health problems or concerns are addressed. This is when your co-pay and deductible will be applied.

Other ways physician's charge separately include anytime they address stopping smoking or drinking. There are procedure codes that will be billed in addition to the office visit, which in turn will cause more out of pocket costs for Medicare patients.

One code that is routinely used incorrectly for Medicare patients is 99211, which is defined:

“Office or other outpatient visits for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.”
Among other things, code 99211 should not be used to bill Medicare:

• For phone calls to patients.

• Solely for the writing of prescriptions (new or refill) when no other E/M is necessary or performed.

• For blood pressure checks when the information obtained does not lead to management of a
condition or illness.

• When drawing blood for laboratory analysis or when performing other diagnostic tests, whether or not a claim for the venipuncture or other diagnostic study test is submitted separately.

• Routinely when administering medications, whether or not an injection (or infusion) code is submitted on the claim separately.

• For performing diagnostic or therapeutic procedures (especially when the procedure is otherwise usually not covered/not reimbursed or payment is bundled with payment for another service), whether or not the procedure code is submitted on the claim separately.


Anytime there is a question about a charge that you feel is unfair or unsubstantiated, please call Medicare to voice your concerns.