A Comprehensive Guide to Geriatric Medical Billing and Coding

geriatic

As healthcare professionals specializing in geriatric medicine, geriatricians play a crucial role in addressing the multiple healthcare needs of the elderly population, particularly those aged 65 and above. These patients frequently present with a variety of chronic conditions and cognitive impairments, which general internal medicine practitioners might not be able to adequately manage.

This article aims to provide a comprehensive overview of medical billing practices tailored to geriatric care, emphasizing the nuances and complexities of billing for services rendered to this demographic.

Table of Contents

Evaluation and Management

The majority of geriatric patients are managed in the outpatient setting, requiring meticulous attention to medical billing procedures during their encounters with geriatric providers. G Given that Medicare or Medicare Advantage Plans cover the majority of geriatric patients, it is crucial for medical billers and coders to abide by the precise rules governing reimbursement for evaluation and management (E/M) services.

The basic format of codes with levels of E/M services is based on medical decision-making (MDM) or time. Resulting in only billing a new or established outpatient E/M 99202-99215, no matter if the patient is scheduled for a new patient or consult visit (Medicare or MAP will not cover consult codes 99242-99245).

To accurately determine the patient’s status, it is crucial to differentiate between new and established patients according to Medicare guidelines.

A new patient is defined as someone who has not received any professional services from a physician or qualified healthcare professional in the same specialty within the past three years.

On the other hand, an established patient refers to someone who has previously received professional services from the same healthcare provider within the specified timeframe.

For more detailed information on evaluation and management coding, review our E/M changes in 2024

Elements of Medical Decision Making
Level of MDM (Based on 2 out of 3 Elements of MDM) Number and Complexity of Problems Addressed at the Encounter Amount and/or Complexity of Data to Be Reviewed and Analyzed
*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.
Risk of Complications and/or Morbidity or Mortality of Patient Management
Straightforward
99202 EP
99212 EP
Patient returns to review lab results. Fatigue has resolved. No additional labs order Fatigue G93.32 patient to return in one year for annual exam. Labs were normal.
Low
99203 NP
99213 EP
Patient comes in with sore throat Strep culture negative separately billable Pain in throat R07.0 return if pain continues
Moderate
99204 NP
99214 EP
Patient with two chronic condition : Hypertension I10 and Type 2 diabetes mellitus with diabetic nephropathy E11.21 Finger stick done in office separately billed Hydrochlorothiazide 25 mg for hypertension and Levemir FlexPen 100 U/ML
High
99205 NP
99215 EP
Patient seen for chronic hypertention high blood pressure reading today and complaining of chest pain. Personally reviewed 3 labs and last chest x-ray done in urgent care 2 months ago when patient had pneumonia. X-ray showed pneumonia. EKG ordered and read in office separately billable Elevated blood pressure with hypertension I10, Chest pain R07.9 and abnormal EKG R94.31 Patient instructed to go directly to the hospital for admission.

Advance Beneficiary Notice (ABN)

In the realm of geriatric care, the issuance of Advance Beneficiary Notices (ABNs) holds significant importance for both healthcare providers and elderly patients. An ABN, formally known as Form CMS-R-131, is a crucial document used by providers, physicians, practitioners, and suppliers to notify Original Medicare (fee for service) beneficiaries when Medicare payment for a specific service is expected to be denied. It serves as a way to let patients know about services that Medicare or Medicare Advantage Plans (MAP) might not cover and, in some cases, transfers potential financial liability to the beneficiary.

Some of the most common services Medicare or MAP plans will not cover are:

  • Consult codes are not payable.
  • Preventative Visits (99387-99397) are not payable for Medicare and some MAP.
  • For services that may not be covered by Medicare or MAP, an Advance Beneficiary Notice

Before signing, the ABN needs to be reviewed with the beneficiary or his or her representative, and any questions raised during that review must be addressed. The beneficiary or representative must receive the ABN far enough in advance to allow them to weigh their options and make an informed decision. The notifier’s staff or subcontractors may deliver the advance.

ABNs are never required in an emergency or urgent care setting. After filling out all of the blanks and signing the form, a copy is handed to the beneficiary or representative. In every case, the notifier must keep a copy of the ABN sent to the beneficiary on file.

When completing the ABN, providers or provider representatives should be sure to complete boxes A-J in its entity, including:

  • Service being rendered, including CPT or HCPCS code
  • Reason why Medicare may not pay for services
  • Estimated cost
  • The patient must indicate if they are willing to pay for services up front prior to Medicare submission
  • Submit payment for service and do not bill Medicare
  • Deny service

Reminder: without a signed ABN and a claim denied for services not payable by Medicare or MAP, the patient will not be responded to for payment.

Mental Status Examinations

The cognitive assessment of elderly patients is a cornerstone for diagnosing and managing conditions such as early-stage Alzheimer’s disease, dementia, and associated neuropsychiatric symptoms. Precision in conducting and documenting mental status examinations (MSE) is crucial for effective patient management and accurate medical billing.

Our E/M code selection will be based on medical decision-making (MDM) or time. Many of your geriatric patients will have chronic conditions and require chronic care, which means frequent visits. Things to remember when documenting the patient’s progress note, assessment, and plan: We should be sure to document their key terms when they apply.

Standardized Cognitive Tests 

Incorporating standardized cognitive assessments into patient evaluations allows for a structured approach to diagnosing cognitive impairments. Frequent in-office testing includes:
  • Mini-Mental State Examination (MMSE): A quick, 11-task assessment covering various cognitive domains, pivotal for initial cognitive screening.
  • Abbreviated Mental Test Score (AMTS): Evaluates the likelihood of dementia, specifically designed for the elderly population.
  • Mini-Cognitive Function Test: A concise screening tool for detecting cognitive impairment, with scoring parameters to gauge the severity of cognitive deficits.
  • General Practitioner Assessment of Cognition (GPCOG): A sensitive instrument for detecting cognitive impairment, encompassing both patient and informant interviews.
  • Montreal Cognitive Assessment (MoCA): A comprehensive tool for identifying mild cognitive impairment and early Alzheimer’s disease.
  • Alzheimer’s Disease Assessment Scale–Cognitive (ADAS-Cog): Assesses cognitive dysfunction levels in Alzheimer’s patients, focusing on memory, language, and praxis.

Cognitive Assessment

For the cognitive assessment segment, it’s important to note that cognitive assessment, along with Care Plan Services can be appropriately invoiced using CPT code 99483. To complete the billing requirements for CPT code 99483, the following service elements must be comprehensively included:

  • Cognition-Focused Evaluation: This includes a detailed patient history and physical examination targeting cognitive functions. 
  • Medical Decision Making: The complexity of medical decision-making, whether moderate or high, should be explicitly documented, reflecting the intricate nature of geriatric patient care. 
  • Functional Assessment: Evaluating the patient’s ability to perform basic and instrumental activities of daily living is crucial, including an assessment of decision-making capacity. 
  • Standardized Instruments for Dementia Staging: Utilizing standardized tools like the Functional Assessment Staging Test (FAST) or the Clinical Dementia Rating (CDR) provides a quantifiable measure of dementia’s severity. 
  • Medication Reconciliation: A comprehensive review of the patient’s medications, particularly those considered high-risk, is vital to ensuring optimal pharmacological management. 
  • Neuropsychiatric Symptom Evaluation: The assessment of behavioral and psychological symptoms of dementia, including depression, using standardized instruments is essential for a holistic care approach. 
  • Safety Evaluation: Assessing the patient’s safety in their living environment, including the ability to operate a motor vehicle, is a critical component of the care plan.

Medicare Wellness Visits

Wellness visits represent a pivotal component of preventive healthcare for patients aged 65 and above, especially those covered under Medicare or Medicare Advantage Plan (MAP) insurance.

These visits, approved by the Centers for Medicare and Medicaid Services (CMS), are meticulously structured to include several aspects of preventive care tailored to meet the unique healthcare needs of the elderly.

Providers should note that some Medicare Advantage Plan carriers will allow providers to also bill for a preventative medicine visit with codes:

  • CPT Code 99387 (64 years and older): new initial preventive medicine services  
  • CPT Code 99397 (64 years and older) established preventive medicine services. 
 

CMS Guidelines state: 

Medicare covers an eligible beneficiary who is no longer within 12 months after the effective date of their first Medicare Part B coverage period and who has not received either an initial preventive physical examination or an annual wellness visit providing a personalized prevention plan within the past 12 months by a healthcare professional.

CMS guidelines state the eligibility criteria for beneficiaries, highlighting that Medicare covers individuals beyond 12 months of their initial Medicare Part B coverage period, provided they haven’t undergone an initial preventive physical examination or an annual wellness visit with a personalized prevention plan in the preceding 12 months. Eligible healthcare professionals include physicians (MDs or DOs), physician assistants, nurse practitioners, clinical nurse specialists, and other licensed practitioners operating under a physician’s direct supervision (as defined in §410.32(b)(3)(ii)).

Medicare Wellness visits are categorized into three distinct levels, requiring the appropriate selection of Healthcare Common Procedure Coding System (HCPCS) codes by providers, medical coders, or billers. These visits are characterized by a comprehensive Health Risk Assessment and a physical examination focused on vital signs. The HCPCS codes, representing various components of the wellness visit, include the use of G codes found in our HCPCS book, such as:

G0402 (Initial Preventive Physical Exam, IPPE): Known as the “Welcome to Medicare” visit, this initial examination is to be conducted within the first 12 months of a patient’s Part B coverage initiation. It serves as an introductory assessment of Medicare’s preventive care services. 

Example: Patient A turned 65, now has Medicare, and is in November of 20XX for their Initial Preventive Physical and G0402 was billed.

G0438 (Annual Wellness Visit—AWV, Initial): Intended for the second year of Medicare Part B coverage, this visit includes a review and update of the personalized prevention plan, regardless of whether the IPPE was completed.

Example: Patient A turned 65, now has Medicare, and is in November of 20XX for their Initial Preventive Physical and G0402 was billed. Patient A now returns in December of the following year for their annual wellness visit. For this visit, G0438 will be billed.

Example: Patient A turned 65 and now has Medicare Part B. During their first 12 months, they did not complete their initial preventive physical exam, and G0402 was never billed. The patient comes in today after having Medicare Part B for 14 months for an initial preventive physical exam. A G0438 should be billed for this visit.

G0439 (Annual Wellness Visit, Subsequent): Beginning from the third year of Medicare Part B coverage, this code is used for subsequent annual wellness visits, ensuring continuous preventive care and assessment.

Example: A patient comes in today after having Medicare Part B for 3 years for a subsequent annual wellness visit exam. This visit should be billed with HCPCS code G0439.

Wellness visits are a cornerstone of geriatric healthcare, designed to preemptively address health concerns and enhance the quality of life for elderly patients. Mastery of the billing and documentation processes for these visits is imperative for healthcare providers, ensuring compliance with CMS guidelines and the delivery of comprehensive, patient-centric care.

Preventive Medicine Services: Medicare Patients CPT Codes ICD-10-CM Codes
G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment Z00.00 General adult medical exam without abnormal findings or Z00.01 General adult medical exam with abnormal findings
G0438 Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit (second 12 months after enrollment) Z00.00 General adult medical exam without abnormal findings or Z00.01 General adult medical exam with abnormal findings
G0439 Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit Z00.00 General adult medical exam without abnormal findings or Z00.01 General adult medical exam with abnormal findings

Advance Care Planning

Advance Care Planning (ACP) encompasses a broad spectrum of face-to-face services, including the discussion of advance directives, health care proxies, durable powers of attorney for health care, living wills, and medical orders for life-sustaining treatment. The objective is to ensure that patients’ healthcare preferences are understood, respected, and documented, thereby guiding future care decisions.

Billing for ACP services is structured around two primary CPT codes:

99497: This code is utilized for the first 30 minutes of face-to-face ACP discussion, covering the explanation and discussion of advance directives, potentially including the completion of relevant legal forms. Do not bill any ACP discussion of 15 minutes or less as ACP services.

99498: This code applies to each additional 30-minute increment of ACP discussion, complementing the primary procedure.

It’s imperative for healthcare professionals to meticulously document the ACP discussion, capturing: 

  • The voluntary nature of the conversation 
  • The details of the advance directives discussed 
  • The participants present 
  • The duration of the ACP discussion 
  • Any changes in the patient’s health status or healthcare preferences 

ACP can be billed concurrently with Evaluation and Management (E/M) services, utilizing codes 99202-99496. The addition of modifier 25 signifies that ACP is a distinct service that is separately identifiable from the E/M service provided on the same day. This billing practice acknowledges the complexity and critical nature of ACP in the holistic management of geriatric patients.

Key elements to consider in ACP include: 

  • Identification and assessment of caregivers, understanding their knowledge, needs, and the social support available. 
  • The development and periodic review of an Advance Care Plan, ensuring it remains aligned with the patient’s evolving healthcare needs and preferences. 
  • The creation of a written care plan that addresses neuropsychiatric symptoms, neurocognitive symptoms, functional limitations, and referrals to community resources as needed. This plan should be shared with the patient and/or caregiver, establishing a clear communication channel and a mutual understanding of the care objectives. 

The components noted above are central to informing, designing, and delivering a care plan suitable for patients with cognitive impairment. Typically, 60 minutes are spent face-to-face with the patient and/or family or caregiver for this service.

Do not report cognitive assessment and care plan services if any of the required service elements are not performed or are deemed unnecessary for the patient’s condition. For these services, see the appropriate evaluation and management (E/M) code.

Advance Care Plan Minutes CPT Code & Units
Less than 15 minutes Don’t bill any ACP services
16-45 minutes CPT code 99497 (1 unit)
46-75 minutes CPT code 99497 (1 unit) and CPT code 99498 (1 unit)
76-105 minutes CPT code 99497 (1 unit) and CPT code 99498 (2 units)

Vaccines

Making sure that elderly patients receive timely vaccinations is similar to the preventive measures taken during childhood, safeguarding against various preventable infectious diseases. The National Institute on Aging (NIH) underscores the safety and efficacy of vaccines in preventing serious, potentially life-threatening conditions in this demographic.

Generally, the adverse effects associated with vaccinations are minor, typically manifesting as localized pain, swelling, or redness at the injection site. This section explores the critical vaccines recommended for geriatric patients, highlighting their significance in maintaining optimal health.

COVID-19 Vaccination: Clinical evidence greatly supports the role of COVID-19 vaccines in significantly reducing the risk of infection. Both initial and booster doses are pivotal in enhancing immunity, especially amidst the evolving viral variants.

Influenza Vaccination: Annual flu shots are particularly crucial for elderly individuals with pre-existing chronic conditions like cardiovascular diseases or diabetes, offering protection against influenza’s severe complications.

Respiratory Syncytial Virus (RSV) vaccination: The Centers for Disease Control and Prevention (CDC) advises individuals aged 60 and above to consult healthcare professionals regarding the RSV vaccine, which guards against this common respiratory virus.

Tetanus, Diphtheria, and Pertussis (Tdap) Vaccination: To maintain immunity against these bacterial infections, a Tdap booster is recommended every decade.

Shingles Vaccination: Even for patients with a history of chickenpox or prior vaccination, the shingles vaccine is advised to prevent herpes zoster, emphasizing its importance regardless of past chickenpox infection or vaccination status.

Pneumococcal Vaccination: This vaccine is a key preventive measure against pneumococcal infections, including pneumonia, with various vaccine formulations available. A healthcare provider can offer guidance on the most suitable option based on individual health profiles.

Travel Vaccinations: For elderly patients planning travel, vaccines should be tailored to their specific destination, activities, and medical histories, ensuring comprehensive protection against regional infectious diseases.

Vaccinations can be easily integrated into routine outpatient visits, wellness checks, or specialized vaccine clinics. In cases where an Evaluation and Management (E/M) service coincides with a vaccination, appending modifier 25 to the E/M code marks it as a distinct service, ensuring appropriate billing.

Preventive Medicine Services: Immunization Administration CPT Codes ICD-10-CM Codes
90471 IA (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) Z23 Encounter for Immunization
Add on 90472 each additional vaccine (single or combination vaccine/toxoid) (List separately to code for primary procedure.) Z23 Encounter for Immunization
90473 IA (includes intranasal or oral administration); one vaccine (single or combination vaccine/toxoid) Z23 Encounter for Immunization
Add on 90474 each additional vaccine (single or combination vaccine/ toxoid) (List separately to code for primary procedure.) Z23 Encounter for Immunization
90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use Z23 Encounter for Immunization
90679 Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use (adults 60 years and older) Z23 Encounter for Immunization
90683 Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use (adults 60 years and older) Z23 Encounter for Immunization
90686 Influenza virus vaccine, quadrivalent, preservative free, 0.5 mL dosage Z23 Encounter for Immunization
90696 Diphtheria, tetanus toxoids, and acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV), when administered to children 4-6 years of age, for IM use Z23 Encounter for Immunization
90697 Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, w PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for IM use Z23 Encounter for Immunization
90700 DTaP product Z23 Encounter for Immunization
90702 Diphtheria and tetanus toxoids (DT), adsorbed when administered to younger than seven years, for IM use Z23 Encounter for Immunization
90715 Tdap product Z23 Encounter for Immunization
Vaccine Adult Medicare Patient ICD-10-CM Codes
G0008 Administration of Influenza virus vaccine Z23 Encounter for Immunization
G0009 Administration of pneumococcal vaccine Z23 Encounter for Immunization
G0010 Administration of Hepatitis B vaccine Z23 Encounter for Immunization

Conclusion

Enhancing Geriatric Care Through Precision in Medical Billing 

We have covered a wide range of important topics in our comprehensive review of medical coding in geriatric medicine, including cognitive assessments, advance care planning, wellness visits, vaccination protocols, and more. This journey underscores the pivotal role that precise medical coding and documentation play in the efficient management of revenue cycles for healthcare providers specializing in elderly care.

Neolytix remains your loyal partner when dealing with the intricacies of medical coding and billing. We are dedicated to reducing the administrative strain of billing so you can focus on providing exceptional patient care. To that end, we offer a full suite of services that are specially designed to meet the needs of geriatric medicine.

We invite you to schedule a free consultation with us so that we can assess your unique needs and provide a personalized solution.

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