Medicare payment method for Psychiatric and preventive services

Psychiatric Services 

Psychiatric services and/or E/M services rendered in an office or outpatient setting, with Interna- tional Classification of Diseases, 9th revision, Clinical Management (ICD-9-CM) diagnosis codes (290-310), are reimbursed at 62.5 percent of the 80 percent Medicare physician fee schedule allowed amount for the service provided. Inpatient psychiatric services are reimbursed at 80 percent of the Medicare physician fee schedule allowed amount.

Preventive Services

Preventive medicine has been addressed by:

* Congress, to insure patient health, thereby reducing Medicare Program expenditures; and

* CMS, to involve physicians in patient care and to enlist their help in educating the public about benefits and coverage policies for preventive immunizations and screenings.

Physicians and healthcare professionals play an important role in utilization of preventive services. A recommendation by a physician is an important influence in determining whether or not beneficiaries decide to be screened. In particular, primary care physicians play a very important role in facilitating compliance with healthcare screenings. Generally, when primary care physicians recommend a screening procedure to patients, patients follow through. Beneficiaries may be unaware of the bene- fits of screening unless their healthcare professionals discuss them and encourage compliance. Phy- sicians should offer screenings according to currently accepted guidelines and should take advantage of every opportunity to recommend preventive care to patients. Reminders should be given at every visit.

Medicare payment fo EKG and X-RAY interpretations

EKG and X-Ray Interpretations

When a need exists to provide a medically necessary X-ray or EKG to an emergency room patient, the following guidelines apply:

* Payment will be made for the interpretation and report that directly contributed to the diagnosis and treatment of the patient.

* Hospitals are encouraged to work with medical staff to ensure that only one interpretation charge is submitted per service. If the hospital physician ’ s repeat reading is for quality control and/or li- ability purposes only, such services are included in the Part A reimbursement and are not sepa- rately reimbursed.

Who Pays the payment First When You Have Other Insurance?

When you have other insurance (like employer group health coverage), there are rules that decide whether Medicare or your other insurance pays first. The insurance that pays first is called the “primary payer” and pays up to the limits of its coverage. The one that pays second, called the “secondary payer,” only pays if there are costs left uncovered by the primary coverage.

If your other coverage is from an employer or union group health plan, these rules apply:


If you are retired, Medicare pays first.

If your group health plan coverage is based on your or a family member’s current employment, who pays first depends on your age, the size of the employer, and whether you have Medicare based on age, disability, or End‑Stage Renal Disease (ESRD):

— If you are under age 65 and disabled, your plan pays first if the employer has 100 or more employees or at least one employer in a multiple employer plan has more than 100 employees.

— If you are over age 65 and still working, your plan pays first if the employer has 20 or more employees or at least one employer in a multiple employer plan has more than 20 employees.

If you have Medicare because you have ESRD, your plan pays first for the first 30 months you have Medicare.

The following types of coverage usually pay first:
No-fault insurance (including automobile insurance)
Liability (including automobile insurance)
Black lung benefits
Workers’ compensation

Medicaid and TRICARE never pay first. They only pay after Medicare, employer group health plans, and/or Medigap have paid.