Currentblue cross blue shield - michiganPolicy BCPFFS 1002

Annual physical examinations

Defines coverage, payment, billing, and provider requirements for annual physical examinations offered as an enhanced benefit under Blue Cross Medicare Private Fee-for-Service (PFFS) plans; applies to Blue Cross Medicare PFFS members and their providers.

Policy Summary

Payerblue cross blue shield - michigan

PolicyAnnual physical examinations

Policy CodePolicy BCPFFS 1002

Change TypeNo material change

Effective DateJan 1, 2017

Next Review Date

Key ActionBill annual physical exams using listed CPT codes and collect applicable PFFS cost sharing at time of service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Once annuallyAllowed frequency for annual physical exam

99381-99387; 99391-99397; 80050Primary CPT codes listed for billing

No member cost sharePreventive visit cost sharing stance

Created 2016Policy dates

Annual Physical Exam Coverage Criteria

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Annual physical exam coverage criteria

Covered when ALL of the following conditions are met:

Benefit applies to Blue Cross Medicare PFFS members as an enhanced benefit beyond Original Medicare

Service is an Annual Physical Examination consisting of a detailed history and hands-on head-to-toe physical assessment (visual inspection, palpation, auscultation, manual examination) to assess overall health and detect abnormalities

Provided no more than once annually

Provided by an eligible provider: MD, DO, Nurse Practitioner, or Physician Assistant

Rendered in a payable location: home, office, outpatient facility, or hospital

Billed using one of the primary covered CPT codes for annual physicals: 99381-99387, 99391-99397, or 80050 (report CPT/HCPCS and diagnosis codes to highest specificity)

Diagnosis restrictions (as specified) are met

Providers follow billing requirements: bill on CMS 1500, report NPI, send claims to local BCBS plan, and use electronic billing where applicable

Provider reimbursement follows plan methodology: provider will be paid the lesser of the allowed amount or the provider's charge, minus the member's cost share; providers may not balance-bill the member

Member cost sharing: there is no member cost share for the preventive visit itself; collect applicable PFFS cost sharing at time of service for covered cost sharing amounts and the member is responsible for full charge for any elected non-covered services

Coding and Payment Details

Primary CPT codes for annual physicalsCPTCovered

99381-99387	Initial comprehensive preventive visit codes by age
99391-99397	Periodic comprehensive preventive visit codes by age
80050	General health panel (listed)

Payment methodology

Payment formulaProvider will be paid the lesser of the allowed amount or the provider's charge, minus the member's cost share.

Balance billingPayment represents payment in full; providers are not allowed to balance bill the member for the difference between the allowed amount and the charge.

Maximum payment referenceMaximum payment amounts are posted on the BCBSM provider website MA enhanced benefits fee schedule (bcbsm.com/providers/.../enhanced-benefits.html).

Provider Eligibility, Locations, and Billing Rules

Billing Rule

Payment conditions and eligible providers for annual physicals

Eligible providers for payment of the annual physical exam include MD, DO, Nurse Practitioner, and Physician Assistant. Payable locations are home, office, outpatient, and hospital. The benefit is payable once annually. Bill using the listed CPT codes and follow diagnosis restrictions as applicable.

Eligible providers: MD, DO, Nurse Practitioner, Physician Assistant
Payable locations: Home, office, outpatient, hospital
Frequency: Once annually
Primary CPT codes for billing: 99381-99387, 99391-99397, 80050
Diagnosis restrictions apply; no age restrictions

Key Definitions

Welcome to Medicare (Initial preventive physical examination)

TimingOne-time visit that must occur no later than 12 months after the beneficiary's first Part B effective date.

PurposeReview of the beneficiary's health status and risk factors, education and counseling about preventive services, and development of a personalized prevention plan.

Coverage under Original MedicareCovered by Original Medicare as the 'Initial preventive physical examination' (Welcome to Medicare).

Annual Wellness Visit (AWV)

Eligibility timingCovered for a beneficiary who has had Part B coverage for longer than 12 months and who has not received either a Welcome to Medicare or AWV within the past 12 months.

PurposeDevelop and/or update a personalized prevention plan based on the beneficiary's current health and risk factors.

Relationship to Welcome visitUsed when the beneficiary is beyond the first 12 months of Part B and has not had a Welcome or prior AWV in past 12 months.

Annual physical examination

DefinitionA hands-on, head-to-toe history and physical performed without relationship to treatment or diagnosis of a specific illness, symptom, complaint, or injury.

Original Medicare stanceOriginal Medicare does not cover annual physical examinations.

BCBSM PFFS stanceCovered as an enhanced benefit under Blue Cross Medicare PFFS with scope and reimbursement determined by Blue Cross.