The cornerstone of value-based care is medical preventative services. Preventative services cover all the steps (counseling and screenings) performed by your medical practice for Medicare patients, with the end goal of preventing and managing life-saving illnesses and diseases.
The good news is that Medicare covers preventative services at little or no cost to patients. Therefore, we highly recommend that you promote the benefits of preventative services to your Medicare clients.
The preventive services and screenings covered by Medicare include all the services in the image below.
Here are the top medical coding and billing categories for billing Medicare preventative services:
1. Annual Wellness Visits
Internal medicine / PCP / Family practitioners can bill annual wellness visits for every Medicare patient. Here are the codes for Medicare annual wellness visit:
G0402 Initial preventive physical examination
- Face-to-face visits
- Services are limited to new beneficiaries during the first 12 months of Medicare enrollment.
- This service is paid only once in a patient’s lifetime.
G0438 Annual wellness visit includes a personalized prevention plan of service (PPS) and the initial visit. This service is paid only once in a patient’s lifetime.
G0439: A subsequent annual wellness visit that includes a personalized prevention plan of service (PPS) for the client.
G0468 Federally qualified health center (FQHC) visit, IPPE or AWV—An FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV.
99497 Advance care planning first 30 minutes—This Includes the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health care professional. It has to be face-to-face with the patient, family member(s), and/or surrogate.
99498 Advance care planning each additional 30 minutes: This includes the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health care professional (List separately in addition to code for primary procedure).
G0136 Administration of standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes.
2. Alcohol misuse screening
Excessive alcohol dependence abuse exposes patients to the risk of accidents, liver diseases, violence, and even some types of cancer. Medicare covers screening for alcohol addiction and counseling for patients with Medicare Part B.
The following are the caveats for this coverage:
• The screening is performed by a physician or an NPP (qualified non-physician practitioner).
• The patient screens positive against the alcohol dependence criteria.
• They are alert and sober at the time of screening.
• They agree to counseling from a primary care physician.
• Positive patients can claim four counseling sessions in a year.
The medical billing codes for alcohol misuse are as follows.
• G0442 – Annual alcohol misuse screening, 5 to 15 minutes
• G0443 – Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
Note: Only one alcohol screening session is covered in a one-year period. Also, the four counseling sessions should be done on different days.
3. Depression counseling
Depression can occur concomitantly with serious ailments such as cancer, strokes, chronic lung disease, and cardiovascular disease. As per Medicare, 16% of patients suffer from depression, and older adults are at higher risk of suffering from depression. Unfortunately, depression is often unrecognized and undertreated in primary care settings. Medicare encourages providers to screen patients for depression under Part A and Part B benefits.
Physicians and NPPs can perform annual depression screenings using any of the tools available. The billing code for the annual depression screening is G0444, and it lasts 5 to 15 minutes. The screening can also be performed via telehealth. The good news for patients is that the deductible and coinsurance are waived.
4. Colorectal cancer screening
The following colorectal cancer screenings are covered for patients with Medicare Part B:
• Fecal Occult Blood Test FOBT
• Colonoscopy
• Sigmoidoscopy
• Barium Enema (as an alternative to a covered screening flexible sigmoidoscopy or screening colonoscopy)
The patients must meet either of these two criteria:
• Aged 45 and older at average colorectal cancer risk (there’s no minimum age requirement for screening
• The patient is at high risk of colorectal cancer – for instance, has a family history or has IBD, Inflammatory bowel disease, or Crohn’s disease.
Here are the colorectal cancer screening codes
• 00812 – Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
• 81528 – Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result
• 82270 – Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutively collected specimens with single determination, for colorectal neoplasm screening (i.e., the patient was provided three cards or single triple card for consecutive collection)
• G0104 – Colorectal cancer screening; flexible sigmoidoscopy
• G0105 – Colorectal cancer screening; colonoscopy on individual at high risk
• G0106 – Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
• G0120 – Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
• G0121 – Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
• G0327 – Colorectal cancer screening; blood-based biomarker
• G0328 – Colorectal cancer screening; fecal occult blood test, immunoassay, one – three simultaneous
Please note the following for deductible and coinsurance for colorectal cancer screening.
For codes 00812, 81528, 82270, G0104, G0105, G0121, G0327 and G0238 the deductible and coinsurance are waived
For codes G0106 and G0120 (barium enema), the deductible is waived, but coinsurance applies.
5. Diabetes Screening and Glaucoma Screening
Preventative services for diabetes cover blood tests to measure sugar levels and identify asymptomatic individuals. The preventative services cover two screenings within a 12-month for a patient diagnosed as pre-diabetic and once every 12 months for a patient not pre-diabetic. Coinsurance and deductibles are waived.
Procedure codes for diabetes screening are as follows:
82947 – Glucose; quantitative, blood (except reagent strip)
82950 – Glucose; post glucose dose (includes glucose)
82951 – Glucose; tolerance test (GTT), 3 specimens (includes glucose)
83036 – Hemoglobin; glycosylated (A1C):
6. Diabetes Self-Management Training ( DSMT)
Your practice can run a personalized care program for patients to help them learn skills to manage diabetes in their daily life. Here are the billing codes for DSMT as provided by Medicare:
• G0108 – Per 30 minutes for an individual.
• G0109 – Per 30 minutes for a group
DSMT can be billed for up to 10 hours of training in the first year of counseling ( over 12 months – not a calendar year) and up to two hours of follow-up training each calendar year after completing the initial 10 hours.
For insulin injection training, you can provide a total of 10 hours or two annual DSMT services through telehealth for insulin-dependent patients with diabetes when clinically appropriate.
Please note that you cannot bill DSMT and Medical Nutrition Therapy (MNT) for the same patient on the same service date or incident to a physician’s or an NPP’s professional services.
7. Awareness of the Medicare Diabetes Prevention Program (MDPP)
MDPP is an enhanced coverage model that offers an evidence-based range of services to help prevent the development of Type 2 diabetes in Medicare patients with prediabetes.
Coverage for MDPP is for patients with Medicare Part B who meet the following criteria:
• A body mass index (BMI) of at least 25 (23 if the patient self-identifies as Asian) on the first session date.
• Met one of three blood test requirements within 12 months before attending their first session:
Hemoglobin A1c test with a value from 5.7% – 6.4%
Fasting plasma glucose test of 110 – 124 mg/dL
Two-hour plasma glucose test (oral glucose tolerance test) of 140-199 mg/dL
• The patient had no previous diabetes diagnosis before the first session date (except gestational diabetes), no ESRD diagnosis, and had not received MDPP services previously.
HCPCS Codes for Medicare Diabetes Prevention Program:
• G9886 – Behavioral counseling for diabetes prevention, in-person, group, 60 minutes
• G9887 – Behavioral counseling for diabetes prevention, distance learning, 60 minutes
• G9880 – Five% Weight Loss Achieved from baseline weight
• G9881 – Nine% Weight Loss Achieved from baseline weight
• G9888 – Maintenance Five % Weight Loss from baseline in months 7 – 12
• G9890 – Bridge payment
Each G-code can be applied only once per lifetime, except for bridge payment, which is paid once per patient per supplier. Medicare Diabetes Prevention Program covers up to 22 sessions within a year. Once again, the deductible and coinsurance are waived.
8. Glaucoma Screening
Glaucoma screening covers tests done to check changes in the pressure of eye fluid, changes in the optic nerve, and changes in visual fields. Patients with Part B screening who meet at least one of the following one of these high-risk criteria are eligible for annual glaucoma screening:
• People with diabetes mellitus
• People with glaucoma in their family history
• Black or African Americans aged 50 and older
• Hispanics or Latinos aged 65 and older
Deductible and coinsurance will apply. Here are the billing HCPCS codes:
G0117 – Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist
G0118 – Glaucoma screening for high-risk patients furnished under the direct supervision of an optometrist or ophthalmologist
9. Hepatitis B Screening and HIV Screening
CDC recommends screening all adults aged 18 and older for hepatitis B at least once in their lifetime.
Annual asymptomatic screening for Hepatitis B is recommended for non-pregnant adolescents and adults identified as high-risk, excluding those with hepatitis B virus (HBV). Pregnant women should be screened during their first prenatal visit for each pregnancy, with additional screening at delivery for those with new or ongoing risk factors.
Here are the billing codes for Hepatitis B :
G0499—Hepatitis B screening in non-pregnant, high-risk individuals includes hepatitis B surface antigen (HBsAg), antibodies to HBsAg (anti-hbs), and antibodies to hepatitis B core antigen (anti-hbc). When performed, a neutralizing confirmatory test is followed only for an initially reactive HBsAg result.
86704 – Hepatitis B core antibody (HBcAB); total
86706 – Hepatitis B surface antibody (HBsAb)
87340 – Infectious agent antigen detection by immunoassay technique (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA], qualitative or semiquantitative; hepatitis B surface antigen (HBsAg)
87341 – Infectious agent antigen detection by immunoassay technique (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA], qualitative or semiquantitative; hepatitis B surface antigen (HbsAg) neutralization
HIV screening is covered for anyone who is at perceived risk or at increased HIV risk, including anyone who asks for the test.
The frequency of HIV screening is as follows:
- Annually, for patients ages 15 – 65, without regard to perceived risk
- Annually for patients younger than 15 and adults older than 65 are at increased HIV risk
- For pregnant patients, three times per pregnancy: when diagnosed as pregnant, during the third trimester, and at labor, if their clinician orders it.
Here are the billing codes:
80081 – Obstetric panel (includes HIV testing) This panel must include the following: Blood count, complete (CBC), and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential white blood count (WBC) count (85007 or 85009) Hepatitis B surface antigen (HBsAg) (87340) HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result (87389) Antibody, rubella (86762) Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592) Antibody screen, red blood count (RBC), each serum technique (86850) Blood typing, ABO (86900) AND Blood typing, Rh (D) (86901)
G0421 – Infectious agent antibody detection by enzyme immunoassay (eia) technique, hiv-1 and/or hiv-2, screening
G0433 – Infectious agent antibody detection by enzyme-linked immunoassay (elisa) technique, hiv-1 and/or hiv-2, screening
G0435 – Infectious agent antibody detection by rapid antibody test, hiv-1 and/or hiv-2, screening
G0475 – HIV antigen/antibody, combination assay, screening
Deductible and coinsurance are waived for Hepatitis B and HIV screening.
10. Lung Cancer Screening and Prostate Cancer Screening
Lung cancer screening is covered when the test is done on an individual with no symptoms or history of the disease. The screening test for lung cancer is performed using low-dose computed tomography. Medicare Part B covers patients who meet all of the below criteria:
• Aged 50 – 77
• Asymptomatic (no lung cancer signs or symptoms)
• Tobacco smoking history of at least 20 pack-years (1 pack-year = smoking 1 pack per day for 1 year; 1 pack = 20 cigarettes)
• Current smoker or quit smoking within the past 15 years
• Get a lung cancer screening order with LDCT
The cover is for an annual dose, and the deductible and coinsurance are waived. You can bill lung cancer preventative screening using the following codes:
G0296 – Counseling visit to discuss the need for lung cancer screening using low-dose CT (LDCT)
71271 – Computed tomography, thorax, low does for lung cancer screening, without contrast material(s)
11. Prostate Cancer Screening
This preventative service is billable after a patient with Medicare Part B has turned 50. You can perform the screening annually using two prostate-specific antigen (PSA) tests that measure the level of PSA in the blood and digital rectal examination (DRE). Here are the CPT codes:
G0102 – Digital Rectal Exam (DRE) – Coinsurance and deductible apply
G0103 – Prostate Specific Antigen (PSA) – Coinsurance and deductible waived
Offering these preventative screening services to your patients is an effective way to ensure their health and safety. It allows your healthcare enterprise to build a better relationship with its clients and increase revenues simultaneously. As stated above, the deductible and coinsurance are waived for most preventative screening tests, which means minimal financial burden for your clients. Would you like to know more about billing preventative services? The PracticeForces expert billing team is just a contact form away.
