Routine Physicals for Medicare Patients

June 1, 2009

I am about to become an employee of a group whose culture is to do “routine annual physicals” (RAP). I had mostly stopped doing physicals for patients with Medicare since physicals are usually not covered (unless by a secondary insurance or Medicare advantage plan).The group I will join usually bills Medicare for RAPs, using the 99215 code, plus an additional charge for (I think) 99397 or some other “preventive” code. Are other practices still using 99215 with Medicare patients? Have there been actions from the OIG to recover overpayments related to the use of 99215 for physicals? Can you offer suggestions that would help me get this clarified? It seems, for example, that an internal audit by someone familiar with Medicare rules would help either reassure me or make it clear that the group is not in compliance with Medicare rules.

Question: I am about to become an employee of a group whose culture is to do “routine annual physicals” (RAP). I had mostly stopped doing physicals for patients with Medicare since physicals are usually not covered (unless by a secondary insurance or Medicare advantage plan).

The group I will join usually bills Medicare for RAPs, using the 99215 code, plus an additional charge for (I think) 99397 or some other “preventive” code. Are other practices still using 99215 with Medicare patients? Have there been actions from the OIG to recover overpayments related to the use of 99215 for physicals? Can you offer suggestions that would help me get this clarified?

It seems, for example, that an internal audit by someone familiar with Medicare rules would help either reassure me or make it clear that the group is not in compliance with Medicare rules.

Answer: Medicare does not pay for routine physicals. It’s just plain not covered, outside the “Intro to Medicare” exam. So, sure, many practices try to hide annual physicals under the 99215. But it’s not covered. You need to provide them as noncovered services, have the patient sign the requisite waiver, then bill the patient. Patients hate this because other practices let them get it for free by cheating the system. It is what it is.

You can sure suggest this practice hire an auditor. CMS also publishes a nice overview of Medicare you can use to educate patients and providers about what is covered. Go to medicare.gov and click on “Medicare and You: 2009.”