wellness visit cpt code list

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Education, trainings and manuals, regulations, news and insights, annual wellness visit (awv) documentation and coding.

A Medicare Annual Wellness Visit (AWV) is not a typical physical exam. Rather, it’s an opportunity to promote quality, proactive, cost-effective care. AWVs help you engage with your patients and increase revenue.

A physician, PA, NP, certified clinical nurse specialist or a medical professional under the direct supervision of a physician (including health educators, registered dietitians and other licensed practitioners) can perform AWVs.

AWV documentation

Document all diagnoses and conditions to accurately reflect severity of illness and risk of high-cost care.

An ICD-10 Z code is the first diagnosis code to list for wellness exams to ensure that member financial responsibility is $0.

Z00.00 — encounter for general adult medical examination without abnormal findings
Z00.01 — encounter for general adult medical examination with abnormal findings

The two CPT® codes used to report AWV services are:*

G0438 — initial visit**
G0439 — subsequent visit (no lifetime limits)

Additional services (lab, X-rays, etc.) ordered during an AWV may be applied toward the patient’s

deductible and/or be subject to coinsurance. Before performing additional services, discuss them

with the patient to verify that the patient understands their financial responsibilities.

More information

For additional information and education, contact us at [email protected] .

*CPT® is a registered trademark of the American Medical Association.

**Code G0438 is for the first AWV only. The submission of G0438 for a beneficiary for which a claim code of G0438 has already been paid will result in a denial.

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Applied Behavior Analysis Medical Necessity Guide

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The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The ABA Medical Necessity Guide does not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any matters related to their coverage or condition with their treating provider.

Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.

The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.

Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change.

Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law.

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Precertification lists

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The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT ® ), copyright 2023 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.

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CPT only Copyright 2023 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.

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This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

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Dental clinical policy bulletins

Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.
While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government.
Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.
Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.
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Medical clinical policy bulletins

Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider.
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Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error.
CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern.
In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members.

See CMS's Medicare Coverage Center

Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change.
Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.
While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans.

See Aetna's External Review Program

The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT®), copyright 2015 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.

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You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.

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Medicare’s Annual Wellness Visit (AWV)

The Medicare Annual Wellness Visit (AWV) is a yearly appointment with a health professional to identify health risks and help reduce them and to create or update a personalized prevention plan. During a Medicare AWV, health professionals should also review any current opioid prescriptions, detect any cognitive impairment, and establish or update medical and family history.

Coding and Billing a Medicare AWV

G0438: Annual wellness visit, includes a personalized prevention plan of service (PPS), initial visit

G0439: Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit

G0468: Federally qualified health center (FQHC) visit, IPPE, or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving IPPE or AWV

Diagnosis code V70.0; Initial Annual Wellness Visit G0438; Subsequent Annual Wellness Visit G0439

Medicare will pay a physician for an AWV service and a medically necessary service, e.g. a mid-level established office visit, Current Procedural Terminology (CPT) code 99213, furnished during a single beneficiary encounter. It is important that the elements of the AWV not be replicated in the medically necessary service. Physicians must append modifier -25 (significant, separately identifiable service) to the medically necessary E/M service, e.g. 99213-25, to be paid for both services.

For example, for the patient who comes in for his Annual Wellness Visit and complains of tendonitis would be billed as follows: CPT ICD9, G0438 V70.0, 99212-25 726.90 (tendonitis)

ACP Tools for the Annual Wellness Visit

The following forms and templates can be customized for use in your practice:

Practice Checklist
Patient Letter and Checklist
Health Risk Assessment :
View a paper version
View an electronic version from HowsYourHealth.org
Women's Prevention Plan
Men's Prevention Plan
Adult Health Maintenance Form
Advanced Care Planning

Patient Handouts

Patient FACTS

For more details about how to bill these codes, see Module 9 of Coding for Clinicians.

Welcome to our comprehensive guide on Annual Wellness Visit CPT codes. Medicare started providing coverage for Annual Wellness Visits on January 1, 2011, as part of the Affordable Care Act of 2010. These visits are aimed at promoting preventive care and developing personalized prevention plans for patients. Understanding the specific codes and guidelines for billing and documentation is crucial to ensure proper reimbursement and compliance.

During an Annual Wellness Visit, healthcare professionals assess the medical and family history of patients, measure height, weight, and blood pressure, review risk factors, and provide counseling services. These visits are divided into two categories: the initial visit (G0438) and subsequent visits (G0439). The initial visit is performed on patients who have been enrolled with Medicare for more than one year, while subsequent visits can be done one year after the initial visit.

To properly bill for Annual Wellness Visits, it is important to use the correct CPT code, document all necessary elements, and adhere to billing and reimbursement guidelines. In this guide, we will provide you with the information you need to navigate Annual Wellness Visit CPT codes and ensure accurate coding, billing, and reimbursement.

Key Takeaways:

Medicare provides coverage for Annual Wellness Visits as part of preventive care services.
Annual Wellness Visits are divided into initial visits (G0438) and subsequent visits (G0439).
Proper documentation is crucial for billing and reimbursement.
Medical professionals should use the appropriate CPT code for billing.
Staying updated on changes in CPT codes and compliance regulations is essential.

Understanding the Annual Wellness Visit CPT Codes

The Annual Wellness Visit CPT Codes (G0438 and G0439) provide coverage for a wide range of services that aim to promote preventive care and develop personalized prevention plans for patients. These codes encompass various assessments and evaluations to ensure comprehensive care and early detection of potential health issues. Let’s delve into the details of these codes and understand how they contribute to the well-being of patients.

Annual Wellness Visit Guidelines

To fully benefit from the Annual Wellness Visit CPT Codes, it is essential to adhere to specific guidelines. These guidelines ensure that healthcare professionals thoroughly assess patients’ medical and family history and perform measurements such as height, weight, and blood pressure. In addition, they include cognitive impairment detection, review of risk factors, establishment of a screening schedule, and provision of advice and referrals for health education and counseling services. By following these guidelines, healthcare providers can deliver comprehensive preventive care tailored to each patient’s individual needs.

Annual Wellness Visit Reimbursement

Medicare provides reimbursement for Annual Wellness Visits. However, it is essential to follow the specific documentation requirements to ensure proper reimbursement. Healthcare professionals should use standardized templates to accurately capture all necessary elements during the visit, such as medical and family history, current providers, measurements, risk assessments, screening schedules, and counseling services. Detailed and accurate documentation supports the medical necessity of the visit and ensures smooth reimbursement. By following the guidelines and proper documentation practices, healthcare providers can ensure that their services are reimbursed appropriately.

Documentation and Billing for Annual Wellness Visits

Proper documentation is essential for the successful billing and reimbursement of Annual Wellness Visits. To ensure accurate and complete documentation, healthcare professionals should utilize a standardized template that captures all the necessary elements. This template should include:

Medical and family history
Current providers
Measurements (e.g., height, weight, blood pressure)
Risk assessments
Screening schedules
Counseling services

The documentation should be detailed and precise, supporting the medical necessity of the visit and providing a comprehensive overview of the patient’s health status. By using a structured template, healthcare professionals can ensure consistency and completeness in capturing the required information.

Furthermore, billing for Annual Wellness Visits should be done using the appropriate CPT code. The initial visit is billed under CPT code G0438, while subsequent visits are billed under CPT code G0439.

By adhering to proper documentation and billing practices, healthcare professionals can effectively manage the billing and reimbursement process for Annual Wellness Visits and optimize patient care.

Medicare and Preventive Care CPT Codes

In addition to the Annual Wellness Visit CPT Codes, Medicare also covers a range of preventive care services through specific CPT codes. These services are designed to promote overall wellness, prevent illness, and detect conditions at an early stage. Medicare covers various preventive care procedures, including screenings, vaccinations, counseling, and behavioral interventions.

Here are some examples of preventive care CPT codes:

99387 – Complete Physical Exam for patients aged 65 and older
99397 – Complete Physical Exam for patients aged 65 and older (subsequent visit)
G0101 – Well Woman Exam
Q0091 – Screening Pap Smear

These codes represent a small portion of the available preventive care CPT codes. Healthcare professionals should review the complete list of preventive care CPT codes provided by Medicare to ensure they are providing all necessary preventive care services to their patients.

When billing for preventive care services, it is important to use the appropriate CPT codes to ensure accurate reimbursement. By following the annual wellness visit checklist and using the correct preventive care CPT codes, healthcare professionals can provide comprehensive preventive care to their patients while maximizing reimbursement.

Understanding CPT Codes and Their Structure

CPT codes, or Current Procedural Terminology codes, play a crucial role in the healthcare industry. They serve as a standardized set of codes used to describe various medical, surgical, and diagnostic services provided to patients. Maintained by the American Medical Association (AMA), CPT codes are essential for effective billing, reimbursement, and documentation processes.

A CPT code comprises three key components:

Numeric Code: This code uniquely identifies a specific procedure or service. It helps in accurately categorizing healthcare services and treatments.
Modifiers: These optional two-digit codes provide additional information about a procedure or service. Modifiers help to indicate, clarify, or modify certain aspects of the service, such as the extent or circumstances of the procedure.
Description: The description accompanying the code explains the nature of the procedure or service. It provides essential details about the medical intervention, enabling healthcare professionals to accurately understand and communicate the care provided.

CPT codes and ICD-10 codes, which are used for describing diagnoses and conditions, are distinct and serve different purposes. While ICD-10 codes focus on identifying and classifying diagnoses, CPT codes concentrate on procedures and services rendered during patient care.

Understanding the structure and components of CPT codes is essential for accurate coding and effective communication within the healthcare industry. These codes enable clear documentation, facilitate streamlined billing processes, and ensure appropriate reimbursement for the services provided.

Categories of CPT Codes

CPT codes are an essential component of medical coding, used to describe the various procedures, tests, and treatments provided to patients. These codes are categorized into three main categories: Category I CPT codes, Category II CPT codes, and Category III CPT codes.

Category I CPT codes

Category I codes are the most commonly used CPT codes and cover a wide range of medical procedures, tests, and treatments. These codes are established and regularly updated by the American Medical Association (AMA). Healthcare professionals use Category I codes to accurately document and bill for the services they provide. They are the foundation of the CPT code set and play a vital role in healthcare reimbursement.

Category II CPT codes

Category II codes are supplementary codes used for performance measurement and quality reporting. Unlike Category I codes, Category II codes are not used for billing purposes. Instead, they are used to collect data on the quality of healthcare services provided. These codes help in tracking and evaluating the effectiveness of interventions, treatments, and preventive measures. Healthcare professionals can use Category II codes to report additional information that may be useful in assessing the quality of care.

Category III CPT codes

Category III codes are temporary codes used for emerging technologies and services that do not yet have established Category I codes. These codes are often used for new procedures, treatments, or technologies that are still in the early stages of adoption. Category III codes allow healthcare professionals to track and report the usage and outcomes of these emerging services. As medical advancements continue, some Category III codes may eventually transition to Category I codes when they become widely accepted and established.

Here is a visual representation of the categories of CPT codes:

Healthcare professionals should be familiar with these categories and ensure they use the appropriate codes for their services. Accurate coding is essential for proper documentation, billing, and reimbursement, ultimately facilitating the delivery of quality healthcare.

Finding and Using CPT Codes

When it comes to finding and using CPT codes, there are several resources available to ensure accurate and up-to-date coding. Whether you need to look up a specific CPT code or stay informed about the latest updates in coding guidelines, these resources can be invaluable.

One well-known resource for CPT codes is the American Academy of Professional Coders (AAPC). They offer comprehensive CPT books that provide detailed descriptions and explanations of each code. Additionally, AAPC offers a subscription-based lookup tool called Codify, which allows users to quickly search for specific CPT codes and access coding guidance.

The American Medical Association (AMA) is another reputable organization that provides coding resources. They offer links to various coding resources on their website, including updates on CPT codes. These monthly updates keep healthcare professionals informed about any changes or additions to the CPT code set.

The Centers for Medicare & Medicaid Services (CMS) also offer valuable resources for CPT code lookup. Their free CPT code lookup tool allows users to search for specific codes and provides additional information about each code. CMS also provides a CPT/RVU Data File license, which allows healthcare professionals to import CPT codes into their billing systems.

Staying current with the latest CPT codes and updates is crucial for accurate coding and billing. By utilizing these resources, healthcare professionals can ensure that they are using the appropriate codes and providing the best possible care to their patients.

Benefits of Using CPT Code Resources:

Access to comprehensive CPT books and lookup tools for quick code searches
Regular updates on coding guidelines and changes to the CPT code set
Additional coding resources and guidance for accurate billing and documentation
Free tools and licenses provided by CMS for easy code lookup and integration into billing systems
Improved coding accuracy and reimbursement rates

Responsibilities of the CPT Editorial Panel

The CPT Editorial Panel plays a vital role in the ongoing development and maintenance of CPT codes. Composed of 21 members, the panel is responsible for revising, updating, and modifying the Current Procedural Terminology (CPT) code set.

Meeting regularly, the CPT Editorial Panel addresses over 200 topics related to codes, descriptors, rules, and guidelines. Their work ensures that the CPT codes accurately reflect contemporary medical practices and services.

Authorized by the American Medical Association (AMA), the CPT Editorial Panel is dedicated to maintaining the accuracy and relevance of the CPT code set. This commitment ensures healthcare professionals have access to standardized codes that facilitate proper billing, documentation, and reimbursement.

For healthcare professionals, it is crucial to stay updated on any changes or modifications to the CPT codes. Understanding the work done by the CPT Editorial Panel helps us provide accurate coding and billing services, ensuring compliance with industry standards and maximizing reimbursement for the services we provide.

Let’s take a look at an overview of the CPT Editorial Panel’s responsibilities:

The CPT Editorial Panel’s dedication to ongoing improvement ensures that healthcare professionals have access to up-to-date and reliable coding resources, supporting the highest quality of care for patients.

Coding Guidelines and Compliance for Medical Professionals

Medical coding is a vital profession that requires formal education, training, and certification. As medical coders, we have the responsibility to accurately assign codes to healthcare services and procedures. It is crucial for us to stay up to date with evolving healthcare regulations, payer policies, and compliance requirements to ensure accurate and compliant coding practices.

Coding errors can have significant financial implications, leading to underpayment, delayed payments, or even non-payment by insurance companies. To avoid these issues, it is imperative that we strictly adhere to medical coding regulations and guidelines.

One of the key regulations we must comply with is the Health Insurance Portability and Accountability Act (HIPAA), which protects patient privacy and ensures the security of medical information. We must always handle patient data in a confidential and secure manner, following HIPAA guidelines.

Additionally, being prepared for coding audits is essential. Insurance companies, government agencies, and other entities may conduct audits to verify the accuracy and compliance of our coding practices. By maintaining thorough documentation and demonstrating compliant coding, we can navigate these audits successfully.

Key Points to Ensure Coding Compliance:

Stay up to date with coding guidelines from organizations such as the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS).
Thoroughly review and understand payer policies and requirements to align coding practices accordingly.
Use accurate and specific codes that best represent the healthcare services provided.
Document the medical necessity of each procedure or service performed to support proper coding.
Ensure proper documentation of any additional services or procedures performed concurrently.
Regularly review and update coding documentation templates to reflect changes in coding regulations and requirements.

In summary, as medical coders, it is our responsibility to adhere to coding guidelines, comply with regulations like HIPAA, and be prepared for coding audits. By prioritizing compliance and accuracy in our coding practices, we can contribute to the overall integrity of healthcare systems and ensure proper reimbursement for the services provided.

Updates and Changes in CPT Codes

CPT codes undergo annual updates to ensure accuracy and relevance in the ever-evolving healthcare landscape. These updates involve the addition of new codes, revision or deletion of existing codes, and the introduction of modifiers.

Staying current with these updates is crucial for accurate coding and billing processes. By keeping up-to-date with the latest changes, healthcare professionals can ensure proper documentation and maximize reimbursement.

Importance of CPT Code Updates

The updates in CPT codes reflect advancements in medical procedures, technologies, and medical practices. They enable accurate reporting of services and facilitate efficient communication among healthcare providers, payers, and regulatory entities.

It is essential for healthcare professionals to stay informed about the updates to ensure compliance with the latest coding standards and guidelines. Failing to use the most updated codes may lead to claim denials or incorrect billing, which can negatively impact revenue and patient care.

Modifiers in CPT Codes

In addition to code changes, modifiers are introduced to provide additional information about the service or procedure performed. Modifiers help convey important details that can affect the reimbursement and understanding of the healthcare service.

For example, modifiers can indicate the side of the body on which a procedure is performed or whether multiple procedures were performed during a single encounter. These modifiers play a crucial role in accurately documenting and billing for healthcare services.

It is important for healthcare professionals to be familiar with the available modifiers and understand when and how to apply them correctly. Proper use of modifiers ensures clarity, accuracy, and appropriate reimbursement.

Benefits of Using Updated CPT Codes and Modifiers

Using the most updated CPT codes and modifiers provides several benefits for healthcare professionals:

Accurate billing and reimbursement: Updated codes and modifiers ensure that the services provided are properly documented and categorized, leading to accurate billing and appropriate reimbursement.
Compliance with regulations: Using outdated codes or failing to apply the appropriate modifiers may result in non-compliance with coding regulations, potentially leading to audits, penalties, or legal issues.
Improved communication and coordination: Updated codes and modifiers facilitate effective communication and coordination among healthcare providers, payers, and regulatory entities, ensuring seamless information exchange.
Enhanced patient care: Accurate coding allows healthcare professionals to provide comprehensive and appropriate care to patients, improving patient outcomes and satisfaction.

By prioritizing the use of updated CPT codes and understanding the purpose and application of modifiers, healthcare professionals can streamline coding and billing processes, optimize reimbursement, and deliver high-quality care.

Skilled Therapy Services and Coverage Guidelines

When it comes to skilled therapy services, including physical therapy and occupational therapy, Medicare provides coverage for these services if they are deemed reasonable and necessary for the diagnosis, treatment, or improvement of a patient’s condition. The coverage is not dependent on the patient’s potential for improvement but rather on the need for skilled care.

Maintenance programs, aimed at maintaining or slowing the deterioration of a patient’s functional status, are also covered if provided by a qualified therapist. This means that even if the patient’s condition may not improve, Medicare still covers therapy services as long as they are essential for the patient’s ongoing care and functional well-being.

It is important for healthcare professionals to properly document the necessity and effectiveness of skilled therapy services to ensure reimbursement. Adherence to coverage guidelines is crucial for successful reimbursement claims.

Skilled Therapy Coverage Guidelines

Medicare has specific guidelines in place for the coverage of skilled therapy services. These guidelines ensure that therapy services are provided according to medical necessity and meet certain criteria. Healthcare professionals should be familiar with and follow these guidelines to ensure proper reimbursement and patient care.

Some of the coverage guidelines for skilled therapy services include:

The therapy services must be provided by a qualified therapist, such as a licensed physical therapist or occupational therapist.
The services should be aimed at improving, maintaining, or slowing the deterioration of the patient’s functional status.
The therapy services should be directly related to the patient’s diagnosis and treatment plan.
The therapy services should be reasonable and necessary for the patient’s condition, taking into account the specific needs and goals of the patient.
Proper documentation should be maintained, including progress notes, treatment plans, and outcome measures, to demonstrate the medical necessity of the therapy services.

By following these coverage guidelines, healthcare professionals can ensure that their patients receive the necessary skilled therapy services and that they are properly reimbursed for their services.

Therapy Students and Coverage Guidelines

Therapy students play a valuable role in the care of patients under the direct supervision of qualified professionals, such as licensed therapists. However, it’s important to note that services provided by students are not reimbursed. To ensure proper reimbursement, a qualified professional must be present in the room, directly supervise the service, and sign all documentation.

Understanding the guidelines and requirements for involving therapy students in the care process is paramount for healthcare professionals. By adhering to these guidelines, we can ensure that students gain valuable hands-on experience while maintaining the integrity of reimbursement for the services provided.

Therapy Student Involvement Guidelines

When involving therapy students in patient care, it is crucial to follow these guidelines:

The therapy student must be under the direct supervision of a qualified professional at all times.
The qualified professional must be present in the room during the service and actively supervise the student.
The qualified professional must assume responsibility for the overall management and direction of the patient’s therapy, ensuring the student’s work aligns with the patient’s treatment plan.
All documentation, including progress notes and any required forms, must be co-signed by the qualified professional to verify their presence and supervision during the service.

Adhering to these guidelines not only ensures compliance with coverage requirements but also allows us to provide a valuable learning experience for therapy students while upholding the highest standard of care for our patients.

Example: Therapy Student Involvement

To illustrate how therapy student involvement works in practice, let’s consider an example:

In this example, therapy student Sarah Williams, under the direct supervision of qualified professional Emily Thompson, PT, assists in the post-surgical knee rehabilitation of patient John Smith. Both therapists co-sign all necessary documentation to ensure compliance with coverage guidelines.

By understanding and adhering to the therapy student involvement guidelines, we can contribute to the education and training of future therapists while providing exceptional care to our patients.

Resources for Coding and Billing

In the world of healthcare coding and billing, it is crucial for professionals to have access to reliable resources. Whether you’re a therapist looking for billing scenarios or a coding specialist in need of guidance, there are several valuable resources available to assist you in your work.

Centers for Medicare & Medicaid Services (CMS)

The CMS is a leading authority when it comes to Medicare coding and billing. They offer a range of publications that provide detailed guidance on coding and billing requirements. Two notable resources from CMS are the Medicare Benefit Policy Manual and the Claims Processing Manual. These publications serve as comprehensive references for healthcare professionals, offering insights into the intricacies of coding and billing for Medicare services.

In addition to publications, the CMS website also offers billing scenarios specifically designed for therapists. These scenarios can help therapists navigate challenging situations and ensure accurate billing for their services.

American Academy of Professional Coders (AAPC)

As a well-established professional organization, the AAPC offers a wealth of coding resources and updates. They provide coding books for various medical specialties, including therapy services, which can serve as a valuable reference in your day-to-day coding work.

American Medical Association (AMA)

The AMA is another reputable organization that provides coding resources and updates. They offer links to coding resources on their website, keeping healthcare professionals up to date with the latest coding trends and developments.

It is important to leverage these resources and stay informed about coding and billing guidelines, as they ensure accurate reimbursement for your services. With the right guidance, you can confidently navigate the complex world of coding and billing, ensuring compliance and maximizing revenue.

Medicare resources for coding and billing

The Annual Wellness Visit CPT Code Guide provides a comprehensive overview of the coding and billing requirements for annual wellness visits. By understanding the guidelines, documentation requirements, and coverage guidelines, healthcare professionals can optimize reimbursement and provide quality preventive care to their patients.

Staying updated on changes in CPT codes and compliance regulations is crucial for accurate coding and billing. It is important to use the appropriate codes and modifiers, follow proper documentation practices, and stay informed about any updates or revisions in the codes.

By following the guidelines outlined in the Annual Wellness Visit CPT Code Guide, healthcare professionals can ensure the best possible care for their patients, promote preventive care, and contribute to overall patient well-being. The guide serves as a valuable resource for healthcare professionals navigating the complexities of annual wellness visit coding and billing.

What are the Annual Wellness Visit CPT Codes?

The Annual Wellness Visit CPT Codes are G0438 (Initial Visit) and G0439 (Subsequent Visit). These codes are used to bill for preventive care services and the development of personalized prevention plans for patients.

What services are included in the Annual Wellness Visit?

The Annual Wellness Visit includes medical and family history assessment, measurements of height, weight, and blood pressure, detection of cognitive impairment, review of risk factors, establishment of a screening schedule, and provision of advice and referrals for health education and counseling services.

How should the Annual Wellness Visit be documented?

Healthcare professionals should use a standardized template to document the Annual Wellness Visit. The documentation should include medical and family history, current providers, measurements, risk assessments, screening schedules, and counseling services.

What other preventive care services are covered by Medicare?

Medicare also covers other preventive care services through specific CPT codes. These services include screenings, vaccinations, counseling, and behavioral interventions to prevent illness or detect conditions at an early stage.

What is the purpose of CPT codes?

CPT codes are a standardized set of codes used to describe medical, surgical, and diagnostic services. They are essential for billing, reimbursement, and documentation.

What are the different categories of CPT codes?

CPT codes are divided into three main categories: Category I codes, Category II codes, and Category III codes. Category I codes describe a wide range of medical procedures, Category II codes are supplementary codes used for performance measurement, and Category III codes are temporary codes for emerging technologies and services.

Where can I find current and updated CPT codes?

Current and updated CPT codes can be found in resources such as CPT books, online lookup tools, and coding resources provided by organizations like the American Academy of Professional Coders (AAPC) and the American Medical Association.

Who is responsible for maintaining the CPT code set?

The CPT Editorial Panel, authorized by the American Medical Association, is responsible for maintaining the CPT code set and ensuring its accuracy and relevance.

What are the responsibilities of medical coders?

Medical coders are responsible for accurately assigning codes to healthcare services and procedures and staying up to date with healthcare regulations, payer policies, and compliance requirements.

How are CPT codes updated?

CPT codes are updated annually, with new codes being added, existing codes being revised or deleted, and modifiers being introduced. Healthcare professionals should stay current with these changes to ensure accurate coding and billing.

What are the coverage guidelines for skilled therapy services?

Skilled therapy services, including physical therapy and occupational therapy, are covered by Medicare when they are reasonable and necessary for the diagnosis, treatment, or improvement of a patient’s condition.

Can therapy students participate in the care of patients?

Therapy students can participate in patient care under the direct supervision of a qualified professional, but their services are not reimbursed.

What resources are available for coding and billing?

Resources for coding and billing include publications from the Centers for Medicare & Medicaid Services, coding resources provided by professional organizations, and online tools for looking up CPT codes.

Where can I find a comprehensive Annual Wellness Visit CPT Code Guide?

You can find a comprehensive Annual Wellness Visit CPT Code Guide in this master guide, which provides an overview of coding and billing requirements as well as guidelines for Annual Wellness Visits.

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CPT Codes for Annual Wellness Visits

Annual Wellness Visits (AWV) are a type of preventive care for Medicare patients. There are many benefits to implementing this type of program, such as improving patient outcomes and filling in gaps in care. However, you must understand the CPT billing codes to ensure your claims are not denied and help drive revenue at your organization.

What Is the CPT Code for Annual Wellness Visits?

There are generally three codes associated with Annual Wellness Visits representing distinct phases in AWV programs:

G0402: This code applies to the Welcome to Medicare visit — also referred to as an Initial Preventive Physical Exam (IPPE). This exam is not an Annual Wellness Visit, but it is valuable for understanding the framework of an AWV program. A patient is only eligible for the first 12 months they are enrolled in Medicare. This one-time visit focuses on gaining a general understanding of health with a vision screen, vital measurements and other assessments. This code will be rejected if you apply it after the 12-month mark of enrollment.
G0438: After 12 months of being enrolled in Medicare, a patient becomes eligible for their initial Annual Wellness Visit. If a patient completes an IPPE, they are permitted to use this initial visit on the first day of the same calendar month the next year. When a patient does not complete IPPE, this code will apply any time after the 12-month mark.
G0439: You must use this code for all Annual Wellness Visits following the initial one. Among the AWV codes, this is the last one you will use, and it's the only one you will use repeatedly.

There are various factors that define an Annual Wellness Visit. There are even differentiators between the initial AWV and all subsequent AWVs. However, you should first make sure you understand the difference between an Annual Wellness Visit and an annual physical .

Requirements and Components for Billing AWV

The requirements and components for an AWV vary based on whether you apply G0438 or G0439.

The G0438 requirements include:

A Health Risk Assessment (HRA)
Medical and family history
List of current providers involved in the patient's health
Cognitive function assessment
Blood pressure, height, weight, body mass index and other appropriate measurements
Risk factors for depression
Functional ability and safety assessment
Screening schedule creation
Risk factors and conditions
Personalized health advice
Advance Care Planning, if desired

The G0439 requirements involve updating all of the above factors. Additionally, the patient must not have received an Annual Wellness Visit in the last 12 months.

Who Can Bill AWV Codes?

Unlike some other billing codes under CMS, Annual Wellness Visit billing does have some flexibility. Practices do not need to hire additional staff for their AWV program, and physicians do not have to be the only professionals involved. Rather than assigning specific tasks and responsibilities to different team members, CMS allows for AWV coverage with any of the following individuals:

A physician
A physician assistant (PA)
A nurse practitioner (NP)
A certified clinical nurse specialist (CNS)
A medical professional or team under a physician's supervision, such as registered dieticians or health educators

AWV billing is also not limited to primary care providers. Select specialty practices can bill for AWVs, such as neurology and cardiology. Regardless of who bills the AWV with CMS, a person is only permitted to receive one AWV per year. For instance, a cardiologist cannot bill for an AWV two months after a primary care provider did — the claim will be denied.

It's not unusual for Medicare patients to see one or more specialists, which can lead to AWV billing conflict. Having a real-time system in place to check eligibility can be a major advantage to all care providers.

Additional AWV Codes

At ChartSpan, we provide eligibility checks for G0438 and G0439 — the core codes for Annual Wellness Visits. However, some AWVs may involve additional codes depending on a patient's needs. Examples of additional codes include:

99497: Advance Care Planning is an optional element of an AWV, and it includes a discussion about advance directives and other care wishes. The co-pay is waived when it's billed on the same day as an AWV.
G0442 and G0443: These codes must be used together, and they apply to an Annual Alcohol Screening and 15-minute alcohol counseling session, respectively.
G0477: This code is for a 15-minute obesity counseling session and it can be billed with IPPE or an AWV.
G0153 and G0154: When an AWV takes longer than the typical service, these codes can be added for prolonged preventive services. The codes represent an extra 30 minutes and an additional 60 minutes, respectively.

Talking About AWV With Medicare Patients

Introducing an AWV program at your practice can help you shift from the Fee-for-Service model to Value-Based Care (VBC) . AWV programs contribute to the VBC model because your practice receives payments based on patient health outcomes. Since AWVs are a form of preventive care, you can identify risk factors in your Medicare patients and take action on those factors to improve patient outcomes and close gaps in care.

The VBC model offers benefits to all parties involved in the healthcare system. Patients spend less to maintain their health, and providers can increase patient satisfaction to keep them coming back for appointments. While practices have to spend more time on preventive care, the time saved on chronic disease management is meaningful. Payers then reduce risks and have stronger cost controls.

When discussing the Annual Wellness Visit with your patients, remind them that this type of preventive care reduces the risk of more severe disease and can improve their quality of life in the long term.

Grow Your Medicare AWV Program With ChartSpan

Annual Wellness Visits offer advantages at many stages in the healthcare system, but they still come with challenges. The greatest hurdle your practice faces is patient eligibility. With specialists and primary care providers capable of billing for these visits, a patient may have already had an AWV without you knowing. Providing AWV services and being denied can diminish the value of the program itself.

At ChartSpan, we have a software solution that supports eligibility checks for your AWV program. RapidAWV™ starts by identifying eligible Medicare patients as they come in for their regularly scheduled appointments. From there, the system checks the HIPAA Eligibility Transaction System (HETS) to determine if a patient has had an AWV with any other provider.

This process allows providers to bill for an AWV when they can guarantee reimbursement rather than being denied following a claim. With our team supporting this function through patient engagement and interaction, your overall approach to billing and care becomes more efficient. Improve patient outcomes, close gaps in care and introduce a VBC model with ease.

Learn more about ChartSpan or contact us to get started with our software.

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Medicare g0438 – g0439: two annual wellness visit codes, medicare benefit: annual wellness visits covered.

Back on January 1, 2011, Medicare started to provide coverage for Annual Wellness Visits. This benefit was included in the Affordable Care Act of 2010. Medicare has two HCPCS codes for these wellness visits for medical billing purposes. The codes are G0438 and G0439 .

G0438 Annual Wellness Visit, Initial (AWV)

Annual wellness visit, including a personalized prevention plan of service (PPPS), first visit.

G0439 Annual Wellness Visit, Subsequent (AWV)

Annual Wellness visit, including a personalized prevention plan of service (PPPS), subsequent visit. Annual Wellness Visits can be for either new or established patients as the code does not differentiate.

The initial AWV, G0438, is performed on patients that have been enrolled with Medicare for more than one year. A patient is eligible for his subsequent AWV, G0439, one year after his initial visit. Remember that during the first year a patient has enrolled with Medicare, he is eligible for the Welcome to Medicare visit or Initial Preventative Physical Exam (IPPE). This exam is billed using HCPCS code G0402. An Annual Wellness Visit code of G0438 should not be used — and will be denied — because the patient is eligible for the Welcome to Medicare visit during the first year of enrollment. For more information on the Welcome to Medicare visit go-to CMS .

What is included in an Initial AWV with PPPS?

Medical and family history
List of current medical providers
Height, weight, BMI, BP, and other appropriate routine measurements
Detection of cognitive impairment
Review risk factors – Review of functional ability
Establish a written screening schedule for the next 5-10 years
Establish a list of risk factors
Provide advice and referrals to health education and preventative counseling services
Other elements as determined by the Secretary of Health and Human Services

The above list is just a summary. Check out MLN Matters Number MM7079 for additional information and links to other Medicare resources on services that must be provided at the AWV and subsequent AWV. Preventative Medicine codes 99387 and 99397, better known to offices as Complete Physical Exams or Well Checks for 65 and older, still remain a non-covered, routine service from Medicare. The Well Woman Exam codes G0101 and Q0091 are covered services.

For additional information, specifics, and more details, visit the CMS or your local Medicare carrier’s website. You can also contact them directly.

Are you billing for the Annual Wellness Visits at your practice? Let us know how it’s going and leave us a message below.

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565 thoughts on “Medicare G0438 – G0439: Two Annual Wellness Visit Codes”

I am having trouble with POS for AWV codes G0444 & G0442 in SNF. Any help?

For the MBG BCBS Medicare policies i am submitting G0439, 99397, G0444 and 93000. I am getting rejections stating missing other procedure code for services rendered. These patients have already been billed G0438 and G0439. Submitting G0439 over a year apart. I dont understand what is missing.

What happens if the Medical Group/IPA pays the AWV visit G0438 and so does the Health Plan; should the provider of service refund the group or the health plan?

A patient had a welcome to Medicare physical and 13 months later came back for another physical. Should this second physical be billed G0438?

That’s correct G0402- Welcome to Medicare preventive care- within 12 month, once in lifetime G0438- from 12 month to 24 month –Once in lifetime G0439- Once in every 12 month for Medicare., Once in every calendar year for Advantage plan

Can you be billed for a Annual Wellness Preventive Visit 99397 (CPT) and Medicare Subsequent Visit G0439 (HCPCS) at the same time?

No, You can only bill one or the Other(Medicare annual wellness OR a Preventive examination)

Is a wellness exam performed within a calendar year or one year and a day from the last wellness?

For Medicare- from the last visit For advantage – once in every calendar year (UHC follows, for other commercial may vary)

How can I get a direct hold of Manny. I’d like to consult for his services.

If a member has a wellness visit in Jan and her pcp retires in June- can the new PCP bill a wellness visit also

No. I mean, the new PCP can bill a wellness visit but they won’t get paid. Patients are limited to 1 preventive/wellness exam per year. So they can’t get another one covered through insurance until January of next year or later.

Similarly, if the new PCP is within the same practice as the retiring one, they cannot bill the patient office visit as a new visit even though they haven’t met the patient before.

Can you bill G8447 along with G0438 on the same visit. I am needing conformation on what I am thinking. Thank you in advance

That would be PRQS code billed at $.01 and can be billed with AVW. We work with a software system that has been specifically created to assist providers and specialties that would integrate with your current EMR or as a stand-alone. It streamlines the AVW/IPPE process and reduced the time the administrative staff and providers must take to make sure they have addressed all requirements. You can contact me if you would like more information. It will truly make the process much easier, and faster, and increase revenue by up to $500 per claim.

CAN A OBGYN BILL A G0439 instead of a G0101 AND A Q0091

Can a nurse, LPN or MA, perform a “Mini-Cog” screening during a visit and pass the score to the scheduled provider? Or does this screening need to be performed by the provider themselves? (ie MD, DO, Nurse Practitioner or PA)

Try billing patient and let patient call their insurance, it usually helps.

can i bill g0439 and 99497 together and if so what modifier

G0439 – z00.00/.01 99497(33 modifier) – z71.89

Yes, Just add 33 modifier to 99497.

what ICD10 CODE DO YOU USE?

Hi Manny This is Dr Hoffman in Florida we spoke many time many moons ago about the AWV and HRA

I have a quick Q If a NP and MD together w a Medicare Provider bill AWV collect the full amount or the discounted NP rate of 80/85% of the GO codes ? My best regards hope to talk to you again very soon Dr EDGAR Hoffman

What is the new reimbursement x GO 438& 439 for this year BCBS intermediary Florida

If we want to bill G0438 with 99214 (complains) can we use modifier 25?

G0438 – Z00.00/01 99214 (25 modifier) – any dx except Z00. I hope it helps

Can a patient who has been on Medicare for let’s say 5 years be billed at a new practice for a G0438 Initial Medicare Wellness after they were billed for a G0439 Subsequent Annual Wellness at another practice? When I check the Medicare website for eligibility, it states patient is due for their G0438 Initial Medicare Wellness but I can see in their previous PCP’s notes that they were billed for a G0439 the year before.

My mother’s insurance was billed a G0439 with a 99214 on 1-5-22. The G0439 code was not covered because it was probably used on 2-8-21. Since she did not sign an ABN, can she billed for the 1-5-22 service? Thanks

One more ytd question: Can an AWV be exactly 365 days apart or should it be 366 days apart? My office is confused. If a patient has an AWV on 2/4/21 can they come back on 2/4/22 or should they wait till 2/5/22?

Kathy, 2/4/21 to 2/4/22 is 366 days. 🙂

Think of it this way. 1/1 is the first day of the year, 12/31 is the 365th day. So they’re fine to come back the same date 1 year later.. just not a day before that.

A patient can have an AWV after 11 full calendar months have passed after the month in which a beneficiary had received and AWV. Your patient will be eligible for their next wellness on 2/1/22.

Thank you for sharing medical wellness codes they are so important.

CAN A G0439 BILLED LESS THAN 12 MONTHS APART OR DOES IT HAVE TO BE AT LEAST 366 DAYS TO QUALIFY? EXAMPLE: BILLED GO439 ON 12/29/2020 AND THEN AGAIN ON 12/16/2021

I hope you had the patient sign an ABN because Medicare will not pay. The service must be a year apart.

Medicare does pay for G0439 in the same month as it was conducted last year even if it has not been a full year. For example, if last year you did G0439 on 2/28 and this year you do it on 2/1 Medicare WILL pay.

Hello Mr. Olivarez, How can I bill for all of these procedures with the appropriate modifier so that they are all paid? G0439 99214-25 99497 93000 G0008-59 90674 71046 81002 36415

In a more precise analysis. Medicare allow the follow up to be in the month of the last visit – Meaning, if you see the doctor 02/16/2022, you can return 02/01/2023.

Thank you for allowing me to share. Hope it helps

Hello Mr. Olivarez,

Patient that have Traditional Medicare under the age of 65yreas of age and have an Annual Wellness Visit is there different guidelines we need to look for or are the guidelines the same across the board as the once that are set for 65 yrs and older.

I am really impressed by your way of presenting the article. Thank you for sharing this great article.

When doing the CPT billing for the Annual visits, if the patient is a non-smoker, and is documented in the Social History of the patient as well as the CPT billing code, is it required or necessary to input the ICD-10 non-smoker? Thank you!

If we bill 99204 mod 25 together with G0438, are we not going to include preventive diagnosis for 99204?

Yes we cannot bill preventive Diagnosis to the OV. Carve out only additional LOS dx and code the OV level.

Hello, thank you for your response. Another thing if we bill the G0438, is it required to have a preventive diagnosis? Or should I say, do we have a specific type of diagnosis to bill it with the G0438? Thank you.

Hello, Is it really appropriate to bill a patient for an AWV if they are not yet established with your practice and you know nothing about their medical background yet?

Thank you for sharing this amazing article. I really liked your way of presenting the article.

Are there any exclusions for an annual wellness visit, such as hospice, cancer, or a permanent cognitive disability?

Hi Guys……….We are an independent Rural Health Clinic. My question is: Can I bill G0439 (CG) G0444 (59) G0442 (59) Or would this be incorrect??? Just looking for some guidance with the Preventive Services……. Any input would be greatly appreciated.

RHCs are paid at an all-inclusive rate for preventive services, so there is no point in adding a 59 modifier to the G0444 or G0442. Still bill them for documentation and cost reporting, but you will be reimbursed your AIR regardless.

Can you charge both a professional and facility fee for a G0438 & G0439?

I submitted a G0438 and G0403 on the same day, same claim, with Z00.00, but they were separated and the G0403 was denied, saying “W – Rejected – This status is set based on the receipt date, the bene submission form, and the RJ me” What does that even mean? Can you bill for the screening EKG or not? Done in office, interpreted by physician on site (same as examining physician).

G0403 ECG is only covered with the IPPE (“Welcome to Medicare” visit G0402) and not the AWV G0438/G0439.

I had a patient come in and tell us they only had Medicare so we did a medicare Annual Wellness exam, but patient has Blue Cross as primary. Can we bill the AWV to Blue cross?

If it’s a commercial Blue Cross plan, you will need to bill it as a 993** preventive exam. Since preventive services are typically covered at 100% there won’t be anything left to bill Medicare as secondary. If it’s a Blue Cross Medicare Advantage plan, you can bill it as an AWV.

Good Morning,

I have seen Mod 25 placed on G0439 for the state of CA. Could that be state specific? If so, why? If not, how would that be corrected if already submitted and not denied.

It is not state-specific to my knowledge. The only time you would apply a 25 modifier to G0439 is if it was billed with vaccines on the same day. When billed alone, no modifier would be required. If billed with an office visit, you’d put the 25 on the office visit CPT only.

I know this question has been asked but I can not seem to get paid for medicare AWW and and E & M visit on the same day. We only bill this when there are significant problems addressed and treated on the same day as the AWW. We bill G0438 or G039 plus 99214 with modifier 25. NEVER get paid for both with medicare. This is the response medicare sends : Contractual Obligation – This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.

Please help. Thank you , Ann

Make sure your modifier is on the E/M (99214). Novitas (Medicare contractor) pays this way in the state of Mississippi.

Hello, We are new to the billing of the Medicare AWV. Do you mail the Health Risk Assessment to the patient prior to the visit, have them fill it out and have them bring it in when its time for their appointment for the physician to review with them? What is the best work flow you all have found for this? Thanks, Jessica

We have seen practices do it several ways. One way is to have the patient complete the HRA prior to the visit in the waiting room or have mailed it/provided it prior to the visit itself. Others have called the patient as a previsit planning and have completed it on the phone with the patient prior to the visit. Lastly some have actually built most of the questions within the AWV template in their EHR and ask and document in the medical record directly.

Split the work. You see the patient face to face at the office for physicals, blood works, BP, HT and WT and contract out the HRA questionnaire to be done remotely online while on the phone with patient by remote/telehealth clinicians like myself through contract arrangement. AWV billing is $173. I charge $50 per AWV completed and uploaded onto your EHR. That means you keep $123. Any additional service you provide during the same face to face visit at the office such as vaccine inoculation, EKG, Pap smear, are billed separately using the actual codes for those services which is different and separate from the AWV code.

We are trying to start implementing the Medicare Annual Wellness Visits (AWV) to generate more revenue and capture this type of annually covered visit for our older patients. Most of our patient population falls into the “subsequent visit” category (G0439), since we rarely accept new Medicare patients. It seems that the easiest way to start billing this code would be to coincide the AWV with a patient’s standard quarterly and/or semiannual medication management appointment. These medication management appointments usually include a review of lab work and refills of any prescription medications that are needed to treat chronic conditions, such as Diabetes, elevated cholesterol, Hypothyroidism, etc.

We have been trying to research how you can bill the AWV code with a normal E&M code, and get paid for both visits within the same service date. Do you have any experience with billing these types of Medicare visits? If so, are you able to provide any clarification on the correct coding and diagnosis codes that allow for the billing of an AWV alone and/or with an added office visit code (such as 99213)?

Below are several examples of our basic understanding of how to bill the AWV and E&M claim for a patient that has a history of chronic conditions including Diabetes Type II (E11.9), Hypertension (I10), and Hyperlipidemia (E78.5). Can you please look at the options and tell us which one is correct, or if none of them are correct? EXAMPLE POSSIBILITY 1: 1. CPT Code: G0439 (All Subsequent Annual Wellness Visits – Covered Annually) – No Modifier Diagnosis Code: Z00.00 (Routine General Exam) 2. CPT Code: 99213 (Established Patient Office Visit) – Modifier 25 Diagnosis Code: E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia) EXAMPLE POSSIBILITY 2: 1. CPT Code: G0439 (All Subsequent Annual Wellness Visits – Covered Annually) – No Modifier Diagnosis Code: Z00.00 (Routine General Exam), E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia) 2. CPT Code: 99213 (Established Patient Office Visit) – Modifier 25 Diagnosis Code: E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia) EXAMPLE POSSIBILITY 3: 1. CPT Code: G0439 (All Subsequent Annual Wellness Visits – Covered Annually) – No Modifier Diagnosis Code: Z00.00 (Routine General Exam), E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia) 2. CPT Code: 99213 (Established Patient Office Visit) – Modifier 25 Diagnosis Code: ***Something other than the chronic condition diagnosis codes listed above*** [Example: R05 (Cough)]

Hopefully this all makes sense, but any clarification or direction that you can provide would be very much appreciated!

check medicare first if wellness is due and try to use Z00.01 . All other codes presented above seems okay.

My wife, b. 05/08/1954, receives her annual physical with our primary provider. Additionally she recently had an annual gynecology visit, without PAP smear, that was submitted as code G0438. As a result, it was denied by Medicare and attempts to get the GYN office to recode it to something besides annual wellness visit have been unsuccessful. What would the appropriate code for the GYN office to use for this procedure? We’d rather not have to pay the $350 fee they are charging.

This should be billed with G0101 for the GYN exam requiring 7 or 11 elements (list found online) and Q0091 if a pap was done.

Hi Toney thanks for reaching out. It’s hard to say what is appropriate to bill since I can’t see the medical record of what services were provided. But I can give you some general information.

A G0438 is an initial Annual Wellness Visit. This code can only ever be billed once. This visit, or service, is basically a series of questions to prepare a personalized prevention plan of service for the coming year. One year later the patient will come back and a G0439, Subsequent Annual Wellness Visit, will be performed updating the information from the initial visit. Then the patient can come back every year for another G0439 These codes DO NOT include a routine physical exam. Medicare does not cover routine physical exams.

A gynecological exam for Medicare is coded using G0101. This exam only includes a cervical or vaginal cancer screening; pelvic and clinical breast examination. Based on what you wrote it does not look like they billed that code to Medicare. Of course, there are service and documentation requirements for billing the code. Maybe they did not meet the requirements to bill or they missed it.

Why did G0438 not pay for your wife? I don’t know without seeing the Explanation Of Benefits from Medicare that states specifically why a code did not pay. Maybe it was the wrong code. Maybe it was already billed by your wife’s primary care provider. Maybe something else.

I know this is probably not much help but it’s the best I could do without more information.

Just had my annual medicare wellness visit with my primary care physician. He did it on 11 March of 2020 and this year on March 17th. The bill was coded as initial visit GO438 $415.00. No medicare coverage. Next Was code High MDM 99215 for $280.00. Medicare paid $142.06. Billed $552.94. Since this was not my initial PPPS what should I have been billed? I have hypertension and take thyroid medication. The Dr did a perfunctory physical.

Judith without seeing the medical records all I can say based on what you wrote is that the doctor may have used the wrong code for the annual visit. If this was not your first Annual Wellness Visit it should have been billed as a G0439, subsequent AWV. That is probably why it was not covered. Medicare would have paid G0439 to the doctor. Again, I would need more info but this is a guess.

Hello! We are a Family Practice clinic from Texas that is trying to start billing for AWV. Most of our patient population falls into the “subsequent visit” category (G0439) since we rarely accept new Medicare patients. It seems that the easiest way to start billing this code would be to coincide the AWV with a patient’s standard quarterly and/or semiannual medication management appointment. These medication management appointments usually include a review of lab work and refills of any prescription medications that are needed to treat chronic conditions, such as diabetes, elevated cholesterol, Hypothyroidism, etc.

We have been trying to research how you can bill the AWV code with a normal E&M code, and get paid for both visits within the same service date. Based on previous responses posted in this thread, it seems that modifier 25 is applied only to the 99213 code. Below are several examples of our basic understanding of how to bill the AWV and E&M claim for a patient that has a history of chronic conditions including Diabetes Type II (E11.9), Hypertension (I10), and Hyperlipidemia (E78.5). Can you please look at the options and tell us which one is correct, or if none of them are correct?

EXAMPLE POSSIBILITY 1: 1. CPT Code: G0439 (All Subsequent Annual Wellness Visits – Covered Annually) – No Modifier Diagnosis Code: Z00.00 (Routine General Exam) 2. CPT Code: 99213 (Established Patient Office Visit) – Modifier 25 Diagnosis Code: E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia)

EXAMPLE POSSIBILITY 2: 1. CPT Code: G0439 (All Subsequent Annual Wellness Visits – Covered Annually) – No Modifier Diagnosis Code: Z00.00 (Routine General Exam), E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia) 2. CPT Code: 99213 (Established Patient Office Visit) – Modifier 25 Diagnosis Code: E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia)

EXAMPLE POSSIBILITY 3: 1. CPT Code: G0439 (All Subsequent Annual Wellness Visits – Covered Annually) – No Modifier Diagnosis Code: Z00.00 (Routine General Exam), E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia) 2. CPT Code: 99213 (Established Patient Office Visit) – Modifier 25 Diagnosis Code: ***Something other than the chronic condition diagnosis codes listed above*** [Example: R05 (Cough)]

Thanks in advance for any help you are able to provide!

Hi Maggie —

This is how I would bill your scenarios.

EXAMPLE POSSIBILITY 2: 1. CPT Code: G0439 (All Subsequent Annual Wellness Visits – Covered Annually) – No Modifier Diagnosis Code: Z00.00 (Routine General Exam) , E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia) 2. CPT Code: 99213 (Established Patient Office Visit) – Modifier 25 Diagnosis Code: E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia)

EXAMPLE POSSIBILITY 3: 1. CPT Code: G0439 (All Subsequent Annual Wellness Visits – Covered Annually) – No Modifier Diagnosis Code: Z00.00 (Routine General Exam) , E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia) 2. CPT Code: 99213 (Established Patient Office Visit) – Modifier 25 Diagnosis Code: ***Something other than the chronic condition diagnosis codes listed above*** [Example: R05 (Cough)]

I would only use one DX on the G0439 and a routine one is fine. I would keep any problem-related diagnoses on the 99212-99215 E&M codes. But I believe what you had was fine.

I have never had any problem billing E/M (25) and AWV on the same day. In 2020, WellCare began to deny all of my AWVs as “not supported by the documentation” following a medical records review by OPTUM. After much discussion, it boils down to some vaguely communicated idea that all chronic problems in the patient’s master problem list must be brought forward into the encounter. Even with the AWV documentation that is provided to both the doctor and the patient by the independent nationwide company that provides our AWV software and support, WellCare and OPTUM still deny saying that there is no proof that the AWV service was actually performed. No other insurance is giving me trouble. I am so confused. PLEASE!!! ANY IDEAS?????

That sounds a bit crazy. Sounds like for them you have to play their game and include a review of the problem list at the time of the encounter if you ever want to get paid.

Claim 99213 , G0442 59 got denied due to NCCI column1 and column 2 problem. How should we bill these 2 codes to get pay? 99213 , G0442 XU ???

Can an annual wellness visit (G0438) can be billed with a dialysis location code (65).

Good morning,

Should coding be done based on higher HCC or higher HCC weight number? please advice

Reply to SUSIE STEVENSON: Hi Susie For our Medicaid payers we bill preventative visits: 99392-25-EP Z00.129 90647-SL Z23 90633-SL Z23 90707-SL Z23 90716-SL Z23 90460 Z23 90461 x 3 Z23 92551-59 Z00.129 and Z01.10 96110-59 Z13.41 or Z13.42

99394-25-EP Z00.129 90472-SL Z00.129 90707-SL Z00.129 90700-SL Z00.129 92551-59 Z00.129 and Z01.10 96110-59 Z13.41 or Z13.42 G0438–Z68.54 – The G code is the Medicare AWV 97803-59 E66.01 (Morbid Obesity), Z68.54, and Z71.3 99401-59 Z71.82 – According to the AAP unable to report counseling codes (99401-99404) in addition to preventative service codes (99381-99385 and 99391-99395) https://www.aap.org/en-us/Documents/coding_preventive_care.pdf – Here is the website I found to be really

We have been billing Medicare AWV (G0402, G0438, G0439) for patients with Traditional Medicare Insurance and 99395-99397 for patients with Medicare Replacement Plans (Humana Medicare, Anthem Medicare, WellCare Medicare, etc) and patients who have Medicare (Secondary) with Dx Z00.00 (Routine General Exam). We bill G0403 (Welcome to Medicare EKG) when G0402 (Initial Medicare AWV)is performed same day. We also bill G0101 (Well Woman Exam) and Q0091 (Pap Screening) for patients with Traditional Medicare. Medicare Replacement Plans we use 99395-99397 with Dx Z01.419 (Encounter for gyn exam) and Z12.4 (screening for cervical CA). Also if provider performs Hemoccult test, we will bill G0328-QW for Medicare (Hemoccult, screening) and 82270 (Hemoccult, screening) for non-Medicare plans with Dx Z12.11 (colon CA screening) and/or Z12.12 (colorectal CA screening).

It has always been complex when physicians are using E&M Code along with other services such as Annual Wellness Visit or Consult Code and if the proper modifier isn’t used, then they will be denied as inclusive. In some cases, we have seen in BCBS that they request clinical docs but in case of UHC and others, they deny for inclusive but it depends on the payer rules, coding combination and few other factors. Thanks for sharing the well-organized article.

I billed 99397 for annual routine gyn exam with G0101 & Q0091 where the preventive code denied not covered by medicare. Can i use G0439 instead of 99397 for reimbursement? Kindly advise.

I don’t think it matters how much you bill to the insurances, they will only pay as per the Fee Schedule and Contractual Agreements. When it comes to the number of services being reported 99214, g0439, g0438. This looks ODD.. Both G0438 and G0439 are AWV Related codes, and one of them is bound to get denied. Apart from the AWV, if you had other medical problems reported which required the provider to spend more than 25 minutes with you, and that was a problem focused service, then 99214 makes sense, but otherwise it should not have been billed in the first place (if there were no other illness the provider treated you on that day).

I went in to the doctor for an annual Medicare exam but when I got the bill it had 3 visits on the bill the codes were 99214, g0439, g0438 all these were for the same visit for a total 0f $747 plus other charges for a total of $1572for about a 20 minute visit to me this seams like an over charge

A provider cannot bill for both G0438 and G0439 in the same 12 months. The office visit 99214 should only be billed if you had a problem addressed.

Hi I have a question regarding using the G0438 and the 99384. We have been billing the G0438 to the wellness visits and have been gotten paid for adult wellness regardless the ins being billed but right now we have a child wellness exam to be billed Dr coded the G0438 and the Z00.00 code, pt has bcbs ins can we still use the G0438 if patient has regular bcbs or do we use the 99384 code? Is the G0438 only strictly used for Medicare patients? Please help and I hope you can understand my question

01/26/2020 Hi, Manny, I have read most of the inquiries regarding AWV. However, my question is will Medicaid paid G0348 if it is a crossover from Medicare? I researched CPT code 99381 and it is not paid by Medicaid so there a conversion code if patient has Medicaid coverage only? Please help I have research everywhere for an answer. Thanking you in advance for your help. REPLYING TO ABOVE QUERY: WHEN MEDICARE PROCESSES AS PRIMARY FOR THE CODE G0438/G0439, THERE IS NEVER A COINSURANCE/DEDUCTIBLE APPLIED, SO THERE IS NO QUESTION OF BALANCE TO MEDICAID.

If you are using the same dx for the G-code and EKG, it is consider as a global.

It is best to perform a G-code service separate from other non-related services with an E&M and modifier.

Linda Pigue CFCHO Nonprofit cfchononprofit.org

Bear in mind, whenever you bill procedure codes with the same diagnosis codes, you position the payers to deny it as a gobal.

For example: 99394 is Preventive Medicine Services, billed with dx Z00.129, with other CPTs with the same dx codes. You should bill with an E&M code and 25 modifier and NOT with the same dx used with 99394.

we are a pediatric office. a normal billing day looks like this: 99394–Z00.129 94702–Z00.129WE 90700–SL–Z00.2129 90707–SL–Z0032129 92551–EP–Z00.129 96110–EP–Z00.129 G0438–Z68.54 97803–25–Z71.33 99401–25–Z71.82 WE ARE NOT GETTING PAID FOR ALL THE PROCEDURES..REJECTION CODES ARE: PROCEDURE OR PROCEDURE CODE IS INCLUDED IN THE PAYMENT/ALLOWANCE FOR ANOTHER SERVICE/PROCEDURE THAT HAS ALREADY BEE ADJUDICATED; OR PROCEDURE OR PROCEDURE/MODIFIER COMBINATION IS NOT COMPATIBLE WITH ANOTHER PROCEDURE OR PROCEDURE/MODIFIER COMBINATION PROVIDED ON THE SAME DAY hOW ARE WE BILLING WRONG

we are a pediatric office. a -00.129billing day looks like this: 99394–z00.129 90472–z00.129 90707sl-=200.129 90700sl–z00.129 92551ep–z00.129 96110ep–z00.129 G0438–Z68.54 97803-25–z71.3 99401–25–z7182 we are gettinhg paid for all the procedures. most of the denial codes says”procedure code or modifier sin not compatible with anothr procedure or procedure/midifier combination provided on the same day” or “the benefit for this service is inclue in the pament/allowance for another service.procedure that has already been adjudicated. are we billing wrong.?wrong

Getting a rejection on the 93000 EKG (treadmill stress test) for medicare when an awv G0439 is present. Does 93000 need a modifier or a no charge and it is considered routine?

IAM GETTING REJECTION FOR BLUE ADVANTAGE PATIENTS FOR G0439 IN CLEARING HOUSE AS TYPE OF SERVICE AND WE ARE USING DIAGNAL CODE IS Z00.01 CLIAM IS NOT GOING TO PAYER IT IS REJECTING IN CLEARING HOUSE ONLY

I have been attempting to research whether Hospice Pts are eligible for a Medicare Wellness Encounter.

I can not find anything definitive.

your assistance will be appreciated in determining whether Hospice pts are eligible for AWV and SAWV.

The question is: I need help. I am billing for WCC (99301 to 99395). Unicare told us we could also bill for codes G0438, G439 abd 97802, 97803 abd 99401), My question is do I use the same DX code on the claim form or do I use different codes, Example of the last claim: DX–Z00.0129, PC: 99394, 90471, 90700, G0438, 97803 33, 99401 25

Answer: I will break down the process: *G0438 and G0439 diagnosis codes should be Z00.00 *Preventative Wellness Visits/ Child Wellness Visits diagnosis codes are either: Z00.110, Z00.129, or Z00.00 ( the AGE determines which dx to use) *If you bill the above with an E&M code–THE DIAGNOSIS CODE HAS TO BE DIFFERENT, CAN NOT be the diagnosis codes above; otherwise it is considered as a global visit. And place 25-modifier on the E&M not the PC above *Other PC codes should be billed with applicable dx for example. 97803 dx relatable code unless that service of care was initially part of the the G-codes or preventative code.

I need help. I am billing for WCC (99301 to 99395). Unicare told us we could also bill for codes G0438, G439 abd 97802, 97803 abd 99401), My question is do I use the same DX code on the claim form or do I use different codes, Example of the last claim: DX–Z00.0129 PC: 99394 90471 90700 G0438 97803 33 99401 25

The question was, “I have the same question. I performed a subsequent annual wellness visit G0439. However during the exam it was discovered he had issues with elevated BP and his cardiac evaluation revealed skipped beats on auscultation and abnormal EKG done at same visit. Question: Can I add modifier 25 to G0439 and bill also for 99213? Also how do I bill for EKG?”

Answer: Add the 25-modifer to 99213 and yes bill a EKG….should be G0439, 99213-25 and EKG should reflect three different primary diagnosis codes.

Also bear in mind, for the EKG, modifier 26 or TC may apply if equipment is onsite or physician is only interpreting it or it is global.

The question was, “What is the criteria to billing Medicare for the office visit 99213 and wellness cpt code G0438 together.? Is there a modifier on the Annual Wellness? Please can someone help. Thanks Rose Mary, Biller for Medicare”

Answer: If you bill G0438 and 99213 the purpose is to reveal two purposes for the visit, resulting in placing a 25-modifier on CPT code 99213, which should have a different diagnosis code not part of the G0438.

The question is, “I need help with the following codes. Everything was paid except for 99497. Do I need an additional modifier g0439, 99213 59, G0444 59, G0442 59, 99497 33, J3420 and 96372 59”

Answer: 99497 is a tricky billing code . Modifier 33 is not needed for that code. Most insurance companies are not familiar with processing that code, so it is denied leaving the provider to justify the reason it should be paid. If it result in a denial, you have to know how to write a strategic letter stating your reasons, according to guidelines and provide proof.

The question was, “Does anyone have an idea if there is a typical average time Medicare recognized for the G0438 and G0439, We are interested in using the new prolong service codes along with this service , prolong service codes G0513 and G0514?”

Answer: Medicare has specified a time frame for G0438 and G0439; however, they have been transparent with provider providing specific information stated below. Seems to be equivalent to a 3rd and 4th level visit. In regards to G0513, make sure documentation states, 30 mins. and G0514 states 60 mins with the particular type of service.

Medical and family history List of current medical providers Height, weight, BMI, BP and other appropriate routine measurements Detection of cognitive impairment Review risk factors – Review of functional ability Establish a written screening schedule for next 5-10 years Establish list of risk factors Provide advice and referrals to health education and preventative counseling services Other elements as determined by the Secretary of Health and Human Services

Does anyone have an idea if there is a typical average time Medicare recongized for the G0438 and G0439, We are interested in using the new prolong service codes along with this service , prolong service codes G0513 and G0514?

What is the criteria to billing Medicare for the office visit 99213 and wellness cpt code G0438 together.? Is there a modifier on the Annual Wellness? Please can someone help. Thanks Rose Mary, Biller for Medicare

I have the same question. I performed a subsequent annual wellness visit G0439. However during the exam it was discovered he had issues with elevated BP and his cardiac evaluation revealed skipped beats on auscultation and abnormal EKG done at same visit. Question: Can I add modifier 25 to G0439 and bill also for 99213? Also how do I bill for EKG?

CPT CODE 99213 IS A COLUMN II CODE FOR G0439. HENCE, MODIFIER (25) MAY ONLY BE USED ON THE 99213 CODE. 93000 CAN BE BILLED WITH 59/XE MODIFIER, BUT YOU WILL HAVE TO ALSO INDICATE HYPERTENSION AS THE PRIMARY DIAGNOSIS

I need help with the following codes. Everything was paid except for 99497. Do I need an additional modifier g0439 99213 59 G0444 59 G0442 59 99497 33 J3420 96372 59

I have a situation where pt has BCBS and we billed the preventive 99397, pt also has Medicare as secondary but his preventive is not eligible for the DOS what are my options in such case? Can I rebill secondary Medicare as a regular follow up(99213) or should I bill this to pt pr write off the charges?

Medicare will not pay for 99397. No, you cannot bill Medicare a 99213 if you performed a 99397 as that would be fraudulent. If BCBS did not pay I would bill the patient for the 99397 unless there is some reason you cannot.

Manny, why is medicare not paying for my g0439 this year?

Don’t know Kent. Ours are getting paid. What are the denial codes and what else are you billing with G0439? Has it been a year since there last G0439 or G0438?

I’m having the same issue! I tried going on supercoder.com and it says G0439 is not a valid code.

Hi Kent! Did you ever get Medicare to pay for G0439 in 2018?

G0439 IS A VALID CODE PER SUPERCODER AND AS PER CMS AS WELL. VERIFY IF A WELLNESS VISIT WAS ALREADY DONE WITHIN THE PAST 1 CALENDAR YEAR. PLEASE PROVIDE RA REASON CODES AND ADJUSTMENT CODES.

Is this correct for Medicare Part B/ Blue Advantage?

G0489 25 z00.00 99497 33 Z71.89 90674 Z23 flucelvax quad single pre-filled syringes G0008 Z23 Admin

Is the Admin code 90471 usually used for BCBS commercial? Thank you for the information!

Please help. My provider was told at a meeting recently that all GCODES can be done by a RN or certified Medical Assistant. He is under the impression IPPE and AWV can be done by them in office as long as he is here in the suite. Please advise.

My limited understanding is that they can do part of it, but the NP or MD must be the one to make the plan and recommendations in order to bill medicare.

Hi Nicole —

The following info is from CMS:

Who can perform an Annual Wellness Visit? Medicare Part B covers the Annual Wellness Visit (AWV) if it is furnished by a: • Physician (doctor of medicine or osteopathic medicine) • Physician assistant • Nurse practitioner • Clinical nurse specialist • Medical professional (including a health educator, a registered dietitian, nutrition professional, or other licensed practitioner) or a team of such medical professionals working under the direct supervision of a physician (doctor of medicine or osteopathy)

Who can perform an Initial Preventive Physical Exam? Medicare Part B covers an Initial Preventive Physical Exam if it is furnished by a: • Physician (doctor of medicine or osteopathic medicine), or • Other qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist)

For the AWV after the RN completes the questionnaire the Physician should then review the questionnaire with the patient and come up with the personalized prevention plan of service for the patient.

Check with your local Medicare carrier for specific information.

SOURCE: https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/IPPE-AWV-FAQs.pdf

Hope this helps.

Please help me with this debate. A group of providers is telling my provider that all Gcodes can be done by a Certified Medical Assistant or RN. Provider is being told AWV,IPPE can be done by them as long as he is in the suite. Please advise 🙂

Does anyone know if you can bill for Advance Care Planning 99497 as a “stand alone” visit with out an office visit charge, or any other charge, or any modifier, and be paid for it? I had a patient come in with an Advance Care Plan he created at home and he wanted me to see it. I looked at it and made some changes to it with him, but nothing else was done. Thank you!

We bill for a 99497 alone and its paid.

Good morning! I am going a little crazy trying to get these paid. Any help would be appreciated. A E/M was billed with wellness visit and patient recieved a steriod injection. Everytime we bill a 96372 they will pay it and deny the 99497 for global. We use the 33 on the 99497 should we do a 25 on the 99497?

G0439 Z00.00 99497-33 Z00.00 99214-25 R09.81,L98.9,I10,E78.2,148.00,M19.90,J449,E03.9,Z98.0 96372 R09.81 J1100 R09.81

Do not use the injection diagnosis with the office visit.

Do not use the injection diagnosis with the office visit

Tawanna, Do you mean to not list R09.81 with the other chronic conditions on the 99214 and only list it with the 96372 and J1100? thanks

Thanks Tawanna for your contribution! We really have a great community. People helping others is what it’s all about.

I have a queston about flu vaccines. We are giving some with our AWV’s. Here are my questions:

How do I bill Medicare Part B (office) for flucelvax quadrivalent, 0.5 ml prefilled syringes, NDC 70461-201-01? with 90674 and G0008 (admin)?

Will these CPT codes change in 2018?

Are the codes different for Blue Cross Blue Shield (of AL) commercial?

Thank you so much for you help!

I am having an issue with being reimbursed from Medicaid for the 99497. Does anyone know why Medicaid will not pay either as Primary or Secondary? Our denials are coming back stating POS and procedure code are invalid, when we speak directly to a Medicaid rep they want a manual fee and additional supporting documentation on a new claim. Please help

99214 -25 99397 93000 j1020 96372

they will pay 96372 and deny 99397, pls help

you need 59 on the 93000 and the 96372

If our provider sees a patient in a nursing home with a 99308, can we also bill a G0439 or G0438 on the same day? Would we use a modifier?

have you solved out your problems?

Our office is doing AWV and we can’t seem to get the depression screening paid for I have paper work that tell me G0444 is not pd with G0402 or G0438 but is pd with Go439 if I put the modifier 33 on the G0444. However that was not pd. When I called medicare they of course would not share what modifier to use. I have had them tell me to use 59 on the G0444 and have also had them tell me to use nothing. I am hoping you will be able to shed some light of this issue for our office. Thank You

It’s my understanding that we perform an AWV during a “follow up visit” where a patient is doing fine but here to discuss their chronic conditions and refill their medicines. For example:

G0438 Z00.00 99213 -25 I25.10 K21

As long as the documentation supports the follow up visit as well as the AWV (even though they overlap a bit). Is that correct?

What I meant to say on that last question/post was that- “can we perform the AWV with a follow up visit (per patient request) with proper documentation supporting both visits (even though they overlap a bit)?” I undersatnd that the patient is responsible for the 99213 portion of the visit. thank you

I have 2 questions please: We recently began performing the AWVs in our office. When we submitted our 1st couple of claims, we didnt’ realize that out practice management made 2 separate claims for the CPT codes -instead of one:

G0438 Z00.00 and 99213 -25 K21, I10 Although Medicare paid them correctly, do we need to fax/mail a Part B Overpayment Refund / Notification form to refund the payments and “clean the slate” then resubmit a single claim with both CPT codes? Or should we leave it alone?

Question 2: I recently submitted this claim to BCBS and it paid without problem:

G0438 Z00.00 99406 -33 F17.210 Z71.6

I sent the same claim (on another patient)to MCR and the 99406 was rejected with an “invalid modifier” After much research, is the correct modifier CG?

G0438 Z00.00 99406 CG f17.201 Z71.6

If so, do I now resubmit the claim with the corrected 99406 modifier even though I know the G0438 is in process and will be paid correctly?

Thank you so much for your help!

We recently met with our Humana Medicare Rep. who let us know that new as of 2017 Humana Medicare is now covering a Annual Physical exam separate of the annual wellness. I believe she said there is a however a $15 copay for the patient. I have since emailed her to confirm that information. Does anyone else know copay amount?

Can I bill for a IPPE with a pap G0101 and a pelvic/breast exam Q0091 at the same visit?

Can you tell me: 1. Can bill for ACP discussion that does not take place with an AWV? 2. Or is it only billable when you provide an AWV at the same time? 3. Is there more than one code for billing ACP, I know of 99497 only. Thank you, Maureen

You can bill for ACP alone in 30 minute increments. 99497 is first 30 minutes, there is another code for additional 30 but that would be a rarity. Do not add a modifier unless it is provided during the AWV.

If provided during the initial G0438 keep in mind that MCR may consider the ACP bundled and will likely not pay separately. If provided during subsequent G0439 it will be paid separately with appropriate modifier.

Hi Chris. I had a patient come in just to bring in an advance care directive he created at home and wanted me to look at it and discuss it. There was no other reason for him to be in the office (no illness, exam or AWV). I want to bill for the time spent on ACP just as a stand alone visit. Do you know if this is possible?

I’m sorry to add onto the forum here but I need to ask, when billing injections do we need to have vitals ? I understand not having vitals for labs but for nurse visit doing injections is it required and a chief complaint require for injection too?

Can I bill this and get paid:

DX is : patient’s BMI & z000 99211 mod 25 86850- TB test G0438 Can you bill G0438 by itself without the modifier and the Z000 DX code? Thank you

A patient came in for an annual wellness visit and a Mantoux test, can this be billed as follows in one visit:?

DX: Z00.00, Z68.36 (BMI) G0438 99213 with Modifier 25 86580

Also can the G0438 or G0439 codes be billed by themselves with the Z00.00 diagnosis codes? Our software does not seem to allow the physician to put in the G codes on his end, without an E/M code. Thank you.

I am a new MCR provider and I saw a MCR pt for a general wellness check up who says he has not been seen by a PCP in several years.Will he be eligible for the initial annual wellness visit G0438? How do I find out whether or not he has been billed for this before?

Well, you should be able to log on to your local Medicare Carrier’s website and check for AWV eligibility. It has been several years since the patient saw their PCP last and they may not know how the practice coded for their services. Make sure you obtain a signed ABN just in case. That way you can bill the patient if needed.

Could another practice haves billed for this? Go to your MAC portal under preventive under eligibility and look for the G0439 code. It will tell you when the patient’s next eligible date is. Could the diagnosis be invalid?

We are billing the Z00.00 and BMI with the G0439 and with the 99214 reg dx codes. It says they are not billable together?

That is interesting Donna because we bill the AWV and a problem-oriented visit and have no problem.

Why is Medicare denying G0439 when it has been over 1yr since last phy? We are charging the G0439 and 99214 plus 25 modifer if needed on 99214. Thanks!

The Medicare portal for your Medicare carrier should have preventive tab under eligibility for your patient(s). This will tell you the next eligible date for G0439. If you have a “stand-alone” practice, you can bill new patient visit with 25 modifier. If your office/HCP is part of a group of doctors billing under the same PTAN/taxonomy, and the patient has had face to face with any of those doctors within 3 years, then you cannot bill new patient visit.

Hi Mr. Olivarez I currently am subscribed to receive your emails and find the information to always be so helpful, thank you so much for all you do! I have a question, if we bill Medicare G0438 and it denied as paid only once in a lifetime; we later find that the pt had this done by another physician can we change the code to G0439 and refile? and also the patient is new to our practice has never been seen if we are allowed to change from G0438 to G0439 can we do so even if the patient is new? I understand that in order to bill G0439 must be within one year of the G0438 but what if it has not been the year, then what do we do? Are we allowed to bill new patient visit 99204?

If I mistakenly billed G0438 I would submit a corrected claim with G0439. It is not relevant, when billing and AWV, that a patient is new or existing. Also, there must be a year between AWVs. I like to say a year and a day to make sure. If it has been less than a year since the last AWV and the doctors perform another AWV, Medicare will consider it not medically necessary. You are free to bill for any problems a new patient comes in for using a new patient EM code.

Our physicians would like to begin reading and interpreting overnight oximetry and PFT/spirometry results for our local hospital. Our physicians would be ordering the test and the local hospital performing the test. Is there a separate, billable profession component for these tests?

Sounds like you would bill using the CPT code for the test and appending a 26 modifier to indicate that you are only billing for the professional component of the code. The hospital should bill the code with a TC since they are doing the technical component of the test.

Medicare will allow an Annual Wellness Visit G0439 twelve months from their last. It can be done on the first day of the month since this last. For example, patient had AWV on 09/15/2016 so he is eligible on 09/01/2017. UHC requires 366 days, so if patient has AWV on 09/15/2016 he is eligible again on 09/16/2017. Do you know the requirements for other health care plans such as Humana, Aetna and any other medicare insurance plans?

Hi Sandy, Sorry I missed your question. I would contact your provider rep for each insurance carrier or go to the plan’s website. As a policy, we tell our providers 1 year and a day for the next AWV and always have the patient sign an ABN.

We have a patient coming in for their AWV G0438 plus a 99497 ACP. Are these the correct diagnosis codes and modifiers?

G0438 -25 Z00.00 plus any other chronic conditions 99497 -33 Z00.00 plus any other chronic conditions

I’m pretty sure that the 99497 requires the -33 modifier but I wasn’t sure about the G0438 with modifier -25

Thanks so much for the help!

You can use modifier 33, preventative service, to tell Medicare that there should be no co-insurance or deductible when 99497 is done on the same day as an Annual Wellness Visit. No need to use modifier 25. ICD-10 codes Z00.00 or X00.01 are fine to use. Check with your local MAC.

what is the difference between G0402 and G0438? We billed Medicare G0402 within the first year of the patient’s eligibility and was paid. After one year, can we bill G04038 or should we bill G0439? I know we can bill G0438 if the patient missed the G0402 within the first year of eligibility.

G0402 is the “Welcome to Medicare Exam” which is basically a routine physical which can only be done in the first 12 months the patient becomes eligible for Medicare. G0438 is the code for the first, initial, Annual Wellness Visit. All subsequent AWVs are billed using G0439. At the AWV the provider discusses a plan of preventive care for the patient for the coming year. There is no physical exam.

To answer your question G0438 would be billed since it is their initial AWV.

Am I correct in assuming G0402 is billed if their 1st Wellness visit is within 12 months of Medicare enrollment

G0438 is billed if their 1st Wellness visit is past 12 months of Medicare enrollment

Can you bill the G0438 in a dialysis setting? The dialysis unit is a clinic owned unit. The provider is seeing the patient doing the wellness visit and then the patient is receiving dialysis. We are billing with POS 65.

Loretta I haven’t come across that one before. I would check with your local Medicare carrier to be sure. If you have already done the service, bill it and see what they say.

LORETTA, IN MY EXPERIENCE WHAT MATTERS IS HOW THE GROUP NPI WAS REGISTERED. IN OTHER WORDS, IF THE GROUP NPI HAS THE TAXONOMIES ADDED FOR BOTH THE CLINIC (AS A GENERAL/FAMILY PRACTICE) AS WELL AS THE DIALYSIS CENTER. IF THE TAXONOMY FOR CLINIC WAS NOT ADDED, THEN YOU MAY NOT BILL THE SERVICE..

What ICD-10 code should be used with G0438 & G0439?

Denise there are two codes you can use.

Z00.00 Encounter for general adult medical examination without abnormal findings

Z00.01 Encounter for general adult medical examination with abnormal findings

Thank you so much Manny 🙂

I have an URGENT QUESTION Regarding billing for “PREVENTATIVE CARE” We have been billing a few cpt codes: These tests are showing medical necessity, but are considered to be PREVENTATIVE IN NATURE: as all of the testing that we are doing is to PREVENT ADDITIONAL ISSUES with the patients: Such as Neuropathies for our Diabetic Patients, Cardiac Issues with our patients with Cardiovascular issues

Can I bill 93923, 95923, 95924,

These codes should pay with a medically necessary problem-oriented diagnosis. Remember it’s what Medicare says is medically necessary.

I also wonder why on the Medicare eligibility website it has a modifier 26 next to the G0438 and G0439 …it is a Professional component…when would that be used?

Lisa I can tell you I would never use a 26 modifier on an AWV code. Can you please share the link to the page you found the info on? Post it as a reply to these comments. I would like to check it out.

It actually was when I went thru connex to look up pts eligibility ….it used to be called entitlements now eligibility …lists what they are eligible for then next to it there is a column with modifiers,eligible date ect …both of the codes have the mod 26 next to it

Same here. The claim for a welcome to medicare G0438 came back with ” N130 Alert: Consult plan benefit documents for information about restrictions for this service.” and saying patient responsible for full amount. Pt swears she had not yet used her brand new Medicare coverage. The NGS site shows the eligibility periods for both G0438 and G0439, both with modifier 26 next to them. What does this mean? Why the denial? I can’t seem to crack this nut. And when you call them, they say they can’t tell you what’s wrong.

Hello Manny, I’ve been reading and studying these post for a couple if days. You are a wealth of knowledge. I am new at coding and have several questions: (I’ll start with a couple as not to overwhelm)

1. I understand the difference between the IPPE G0402, 1st AWV(G0438) and subsequent AWV (G0439. I was wondering which Dx codes should be used with the visit…Z00.00/ plus any Chronic Condition codes? I understand that Z00.01 can only be used if an abnormal finding was found on that day.

2.I have CAHABA GBA InSite web portal which allows me to check patient eligibility (entitlements) for preventative services. On the page I can see, it shows the date the patient is eligible for certain services. If it says the patient is eligible for the IPPE on the same day they became a Medicare beneficiary (for example in 2012), then I assume the patient never received this G0402 IPPE visit and can longer receive it since it has to be done within the first 12 months on Medicare. I also see that her G0438 & G0439 has an eligibility date of 1/1/2013. It also has a Modifier column on the screen which states 26. What does this 26 mean? (I know that it means Military treatment facility in the CPT book but she isn’t Military) And do we perform the G0438 with the Dx code Z00.00 plus any chronic conditions? Thank you for you help. I’ve researched for days trying to find a place to ask questions.

Sincerely, Constance

Can we bill an annual wellness exam and an E & M code (ex 99214) for the same patient, on the same day, in the same office setting, but with different providers within the office? One provider saw the patient for the wellness exam and another saw them for a checkup.

Yes you can bill for both an AWV and an E&M code. In your scenario you indicated that another doctor saw the patient for a checkup. By checkup if you mean a routine physical exam its not covered by Medicare and you would bill the patient. If female and a pap and breast & pelvic exam were done then you would carve those services out of the checkup and bill that portion to Medicare.

I have providers wanting to report an AWV along with a problem oriented visit and a physical examination on the same date for those that carry insurance that will cover the physical Exam. I have not seen this done and my concern is that too many components of the PE and the AWV would overlap to support reporting both services. Does anyone have any reference sources that would support reporting or not reporting all three together. Again, concern is with the CPE and the AWV – same date.

I am a consultant and I help practices launch internal AWV programs. Any time that my client wants to do this I always advise them that proper compliance would be for the PE to be completed and billed on a separate visit (preferably on a visit AFTER the AWV has been done). Every year the AWV can be used for screening purposes (along with a regular problem oriented visit), and then the PE can occur on the patients next visit. Rationale being that the AWV should have established a ‘goal’ for what conditions or risk factors would be addressed for the next 12 months as the PE has patient edu components. See how it all comes together?

Chris great advice. We do have a practice that has done the AWV, a PE and a problem-oriented visit all on the same day. The documentation is separate for all visits. The provider uses the AWV as a’goal’ like you indicated and then goes on to perform the PE and at times, if warranted, a problem visit.

You did mention proper compliance is that the PE is to be performed on a separate visit. Do you have a link with documentation from CMS on this that you could pass along?

Can anyone please tell me exactly what documentation is required for a medicare wellness visit? I am new to this and I am getting differing answers from my management.

Megan this info from Medicare should help: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7079.pdf

Hello, I am wondering if anyone knows where you can find examples of when an E/M code can be billed in conjunction with an AWV (G0438 or G0439). I want to make sure that we are billing E/M services when appropriate. Also, any information in regards to what documentation is required above any beyond the AWV note would be helpful. Thank you

An E/M code can be billed in conjunction with an AWV anytime that a patient presents with a symptom that requires diagnostic evaluation by the physician, is medically necessary, and is separately identifiable.

As an example, say a patient is being seen for an AWV and they have a severe cough that they also want addressed. The doctor can address this separately at the time of the visit and both services can be paid (for example G0438/9 with Z00.01 and 99214 with J44.9). This example uses unspecified COPD as an example of the ‘sick visit’ reason.

With regard to documentation what do you mean by AWV ‘note’? There is actually quite a bit of documentation required for Annual Wellness Visits. Can you be more specific?

Hope this helped

Do Medicare Annual wellness visits have to be done in clinic. Can they be done over the phone or at home such as home visit?

No, the AWV can be done at a home visit. I believe a phone call would fall under Medicare’s telemedicine guidelines.

Here is a link to some information from Medicare: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf

So can the AWV be performed in the home under Rev code 522 in RHC setting? You say “NO, it can be done at home” so I wasn’t sure if the answer is yes or no??

Sorry, let me clarify. To answer Randell’s question, no the AWV does not have to be done in a clinic, the AWV can be done at a home visit. Now RHCs have some different rules but I believe still you can. Check it out.

Thank you for this information – could you please help direct me to further information or a government/CMS source describing that the AWV can be conducted during a home visit (I cannot seem to find this mentioned anywhere)?

Jason, I too cannot find a list of place of service codes where an AWV can be performed. I see mentions of where they cannot be performed such as POS 13 and 32 but I don’t see a POS 12. We bill for them at patients home the AWV pays.

Manny, Please see the following response by you regarding AWV’s and POS codes 13 and 32. You state in this article that they are permitted yet below you state that they are not. Can you please site your source for either.

We are getting refund requests from UHC Medicare Solutions for G0439 visits. We filed with ICD10 Z00.00 as always – they paid the claims and now they are telling we used the incorrect ICD-10 code, although they can’t tell us what code they will accept. Suggestions from anyone??

the only other code you can use is Z00.01 which is abnormal physical- and we determine that in our office if the patient requires follow up visits after that physical then they are abnormal.. I rarely use normal except for younger adults

Thoughtful piece – I learned a lot from the facts. Does someone know where I would be able to obtain a fillable PDF Calendar example to work with ?

Do you have to use a modifier for G0438 if you are providing this in conjunction with 99497? Do you need a modifier for the 99497?

CPT 99497 should have a 33 modifier attached. Here is some information on billing the 99497 with the AWV: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9271.pdf

So no modifier for G0438?

Correct, no modifier is needed for G0438.

Manny, Hello if I am understanding the process of billing the AWV we can not use the DX code of Z000 on the claim when billing, should we be replacing that with another DX code to get the AWV covered and paid by Medicare?

Our docs use Z00.00 or Z00.01 for the AWV with no issues getting paid.

I we are doing the AWV at our practice and we are billing as follows CPT/Mod/Dx:

G0438/Z00.01 G0444/33/Z00.01 9949733/Z00.01 99213/25/X

Now I know that G0444 doesn’t get paid with G0438 which is fine but what is interesting is that Medicare will pay for G0438, 99497, and E/M for a few…..but most come back just paying G0438 and 99497.

Why would this be? Reason we are given is a ’49’ saying E/M isn’t paid because it is a preventative service??? ????

You can not use Z0000 with Medicare and Medicare plans as they do not pay for preventative services, you can only use diagnosis codes. Make sure Z0000 is not listed anywhere on the insurance claim form or it will get denied.

Hi Manny you can disregard my last comment and question turns out the docs we’re also using Z00.01 on the E/M which of course would cause it not to be paid as that is not a problem related diagnoses.

The TB test was 86580 with the admin code 96372 we also billed G0439 . I will remove the 25 modifier and see if the G0439 will get paid.

I billed a G0439 with a 25 modifier on the G0439 also on the same day we billed 86580 TB and 96372. I was denied by medicare for the following reason . The procedure code is inconsistent with the modifier used or a required modifier is missing. Should I not be billing for the 96372 administration fee . or am I using the wrong modifier . There are asking me to resubmit a new claim with the requested information. Any info would be greatly appreciated.

SANDRA YOU MAY NOT USE THE MODIFIER 25 WITH THE CODE G0439. I AM ASSUMING THAT “TB” YOU MENTIONED IS NOT A MODIFIER THAT YOU USED ON THE CLAIM. IF IN THE AFFIRMATIVE, JUST BILL THE CLAIM WITHOUT THE MODIFIER 25 ON G0439.

what new rules have changed? we have been using that modifier for years with that dx so this makes no sense.

G0438-G0438 dx Z00.01 99211-99212 modifier 25 with dx Z11.1 and any other problem codes 96372 with dx Z11.1 86580 with dx Z11.1 this is for annual well visit with abnormal findings and TB skin test.

I don’t think you need a modifier code for straight Medicare if it is during the G0439 visit. If it is a level 3 then you do use the modifier code

Becci we have been using the modifier for years… if they are Medicare or replacement plans doesn’t matter. if you read my initial comment below it has been happening this past few months, and I wasn’t the only person who responded. So this is a new issue.

My suggestion is bill G0439 w/ your z00.00 & 86580 z11.1 only, B/c Reporting 96372 for placement of the PPD is inappropriate the administration is inclusive. I would also bill for the reading of the TB when coming back but only report 99211 if the nurse evaluates the tests results and documents.

I am billing a 99213 w mod 25 g0439 g0442 & g0444 and I am getting a denial.

So since August we have always had no problem with G0439 with a 25 modifier if we are doing any vaccines in office or other procedures we can charge for…but our new EMR system this year keeps pooping this up now: 08/15/2016 AUTO SCRUB PRIMARY HOLD Rule: Procedure Code/Modifier Mismatch [359]

[Medicare] Modifier 25 is not listed as reportable with procedure G0439. Please review the procedure coding and modifier usage on the Claim Edit screen. To help you resolve this issue, more information on modifiers that are appropriate for procedure code G0439 can be found in athenaCodesource.

I go to their code source and all I see now is a 99 modifier which I have never used…anyone else having issues or is it just Athena’s EMR

Did you get any resolution to this? I’ve been having the same problem and contacted Athena and they said maybe medicare changed their rules. They have not.

No I have not- I have tested a few claims with sending w/o the modifier so I can keep tabs on and some with the 25- and having to force drop with a CCO – I agree you think we would have heard this at the beginning of the year not in the middle!

Kristen I went to look at the charges I have done with and without the modifiers and both types of claims have been paid. I just do the CCO override on Athena until they fix their mess…because it proves no point.

I was recently advised to consider adding the AWV to our SNF providers list of things to do. I reviewed several of your past posts to see what you thought. I do not see answers to the SNF posts. So I will ask a different way.

Does the place of service matter with the AWV or the IPPE? (I do see the post on home health, thank you. I am most interested in SNF if you have this information.)

We have a patient that had her Welcome to Medicare (G0402) in July of last year. Of course she’s new to us and said she hadn’t had a physical or anything of the sort in the past few years. Because we had new front office staff, they did not call Medicare with the question prior to the patient visit. We billed the G0402 and was denied. We refiled with G0438 and have been denied again because we did the exam in April of this year and it’s been less than 12 months. Are we able to bill the G0439 or are we just going to have to bite the bullet for this one?

Jessica, first of all a G0402 is different than a G0438. Did the provider perform and document all the elements of a G0438 when the Welcome to Medicare exam was done?

There is still a 12-month minimum time when performing any Annual Wellness Visit so a G0439 would not fly.

Now with an AWV you do not need an ABN signed so you are able to bill the patient for the visit and get paid.

So you can either bill the patient the full amount or start biting that bullet and write off the claim.

Thanks so much for the timely reply. I understand the differences between the codes. The provider had adjusted the note to reflect the different code being billed since the correspondence had originally come back within 14 days of the pt visit. Yes, the provider did document everything associated with the G0402 and G0438 because he wasn’t sure which one he was doing originally.

I did not know that about the AWV and ABN… thank you

My GYN doctor said they can’t use the G code because they aren’t my primary doctor.

Kathleen that is not true. A GYN can do an Annual Wellness Visit. My guess is that they don’t want to becasue they are afraid that the primary doctor may have done the visit previously and the GYN will not get paid.

This visit can only be done once every 12 months. We have had doctors perform the service only to find out later that the patient had a wellness visit from another doctor within the 12 month period resulting in the claim being denied and the doctor not getting paid. And yes, the patient had told the doctor that they had not had one in the past year.

Now the doctor can have you sign what is called an ABN, Advanced beneficiary Notice. This notice that you would sign states that if Medicare does not pay you will be financially responsible. This way the doctor can bill you if the visit was done within the past year by another doc and Medicare doesn’t pay. Without the ABN signed the doctor cannot bill the patient.

One other thing to note is that the Annual Wellness Visit is not a routine annual exam. That exam is never covered by Medicare.

You can go to your Medicare portal, go to Eligibility, complete the info. Then pick preventative. (At least in CGS). Sort by code, and it will tell you when patient is eligible for whichever preventative code, G0439, etc.

I am having a HORRIBLE TIME billing for medicare GYN exams!!! I dread each call of a patient calling about the balance!!!! Then they call medicare and they just tell the pt we coded it incorrectly to get them off the phone. Then they call us for the 100th time and we explain the same thing and get yelled at.

I wish medicare would actually explain that the well woman portion 99397 is NOT covered instead of just trying to get them off the phone!!!!

Are your providers billing for the G0101 and the Q0091? You are you carving those 2 codes out of the 99397 and billing the patient the balance? Are the providers and/or the front desk telling the patient that a provider will be doing a full physical and only the gynecological exam part of it exam may be covered by Medicare?

Carolyn Dunn over at Rio Grande Hospital saw your post and emailed me and said: “My understanding is that the gyne exam code is G0101, not 99397 which Medicare will not pay for. Gyne exams can only be done every 2 years unless the patient is high risk.”

Carol also said:

“Currently we would bill the G0438 or G0439 and if a gyne exam G0101 only if that hasn’t been done in the past 2 years. We currently do not bill for the Q0091, it’s not in our Charge Master. We have not been billing our Medicare patients the 99397, we only do the annual wellness exam. If we address anything else in addition it is usually and E/M code with modifier 25.”

I am still not getting paid for what I believe KS Medicare says is allowed. I bill G0439(well exam), 99497-33 (rvw health care directive), G0444(screening depression), G0442 (screening for alcohol abuse)Medicare is only paying on G0439 and 99497-33. How do I get G0444 and G0442 paid?

SCREENING CODES, (DEPRESSION, FALL) ETC., WILL NEVER GET PAID WHEN YOU BILL THE CLAIM FOR ANNUAL WELLNESS VISIT, WHERE THE SCREENING CODES ARE DEEMED TO BE BUNDLED.

You must use modifier XU on those. Be sure you do or Mcare will split the claim then they won’t pay since not included with the G0438/9. The depression screen is included in the wellness and/or G0402.

Hello Tarra,

From my understanding, you should be getting reimbursement for your screenings (G0444, G0442) because you are billing it with G0439. Those screenings are not bundled into subsequent visits, so it is acceptable to use those G codes. My suggestion would be to use a -59 modifier and see if that works. Medicare tends to look for the -59 modifier and will send back claims without it.

We have been using the modifier 59 on G0444 when doing G0439 and we are not getting paid

What if your patient never had an IPPE as they were already enrolled in MCR when the services started …how do they get their one time only screening EKG? how do we code for that? Thanks!

The rules indicate that the beneficiary must have their IPPE within the first 12 months of Medicare Part B coverage. As long as your patient hasn’t been enrolled for over a year then you should be able to bill out the G0403 (or G0404, G0405) following Medicare’s guidelines: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf

“Effective January 1, 2009, the screening EKG is billable with HCPCS code(s) G0403, G0404, or G0405, when it is a result of a referral from an IPPE” https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm6223.pdf

Are you trying to bill only for the EKG? Or for the entire IPPE?

Hi, WE HAVE BEEN BILLING THE G0438 AND G0439 CODE SINCE 2011. THE DOCTORS HAVE FOLLOWED ALL BUT ONE GUIDELINE. IN THEIR PROGRESS NOTE, THE WORD PHYSICAL WAS USED AND NOT THE WORD “WELL VISIT”. THE DOCTORS ACTUALLY DID BOTH BUT DO NOT BILL THE CODE 99397. IF AUDITED, COULD MEDICARE RETRACT PAYMENT FOR THE G0438 OR G0439 DUE TO TERMINOLOGY.

PAULA CENAC

Can I bill a 99214 instead of the HCPCS code of G0438, G0439 before enrolling a patient into Critical Care Management? Or do they have to be combined?

CMS requires an AWV, Welcome to Medicare Visit, OR a comprehensive E/M before CCM services can be billed. A 99214 should cover it.

ERIC, 99214 ITSELF IS A LEVEL 4 E&M SERVICE. WHEN YOU DO A ANNUAL WELLNESS VISIT G0438/G0439, A COMPLETE SYSTEM REVIEW IS ALREADY DONE, WHICH TAKES THE PROVIDER ALMOST 45 MINUTES. IN THESE SITUATIONS, THE INSURANCE MAY WANT TO KNOW THE REASON FOR BILLING A LEVEL 4 E&M SERVICE, WHICH AGAIN INVOLVES AT LEAST 40 MINUTES OF PROVIDER TIME. BETTER BILL A LOW LEVEL E&M CODE 99212, ALONG WITH THE WELLNESS SERVICE, AND MENTION THE REASON FOR REFERRING THE PATIENT TO CRITICAL CARE IN THE PATIENT’S CHART.

Can a PCP provide AWV at a patients home? I don’t see that specific POS on the MM7079. He is not home health- just a PCP that provided a home visit and completed the AWV at that time.

Yes in my experience, I have seen Annual Wellness Visits being done at Home, POS 12. THis is acceptable by insurance.

Do you have to spend greater than 15 minutes with the patient to justify G0444, or can it be less than 15 minutes?

Based on the regulations from CMS the code is built for a 15-minute screening service so you will have to meet the minimum 15-minute requirement in order to bill.

Here is a link from CMS regarding this code:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7637.pdf

EVERY TIME WE BILL THE G0444 IT ALWAYS COMES BACK DENIED. I KNOW PER MEDICARE IT IS A BILLABLE CODE EVEN WITHOUT MOD 59 IT ALSO IS LINKED TO Z13.89 BUT EVERY CLAIM WE BILLED COMES BACK DENIED.. IT IS BEING BILLED WITH GO439 AND 99214 WITH MOD 25 ON THE OV ANY SUGGESTION ON HOW TO GET G0444 PAID

I am billing G0439, G0444, 99497-33…Medicare is not paying for the G0444, I have tried modifier 25 and 59 on the G0439 but still not working. Medicare customer service is no help..Any ideas on how to get all 3 paid?

What are the denial codes from Medicare on the G0444?

This is a very useful link from MLN Matters in reference to billing out the G0444: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7637.pdf

Things to look at for the denial on the G0444 based on this article include the POS limitations and there is specific information based on the denial codes from the Medicare remit.

Also there is a strict time limitation, did another provider perhaps provide the G0444 within the 12 month period? Take a look at the above link with the specific denial reasons.

Additionally, here is some information on billing the 99497 with the AWV: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9271.pdf

This link for a discussion thread also references specific diagnosis codes that may help you: http://coalitionccc.org/2015/10/advance-care-planning-codes-included-in-2016-physician-fee-schedule/

And this link also discusses diagnosis coding: https://www.connecticare.com/providers/PDFs/PreventiveServicesList_Medicare.pdf

We are seeing rejections from Medicare when billing G0438 Mod-25 Z000 with EM code (99213 + Problem DX). Medicare is rejecting with CO16 and M20 when we bill this. Anyone seen this as well? Should the EM / Problem have the Mod-25? What additional info is medicare wanting for these claims?

You should always have the 25 modifier on the E/M ….”25″ modifier is a E/M modifier and not preventative modifier…..file a corrected claim or call CER line and add the modifier 25 to your office visit and remove it from your AWV and your claim will pay.

Modifier 25 should have gone on 99213. We bill this same scenario and it gets paid.

I am dealing with Caresource Just4Me witch is a Marketplace Exchange plan & they pay claims at medicare rates. When 90715 is billed with Revenue code 636 that line gets denied stating “Submitted revenue code has been billed without a needed HCPCs code or was submitted with an invalid HCPCs code per established guidelines” when reviewed by coding Im told the rev code & HCPCs codes are correct so whats the issue?

Wish I could help but we don’t deal with revenue codes. Can anyone else here help Bell?

how to do tell if a patient has had their yearly wellness exam or f/u exam? is there a website that lets you know?

Sunny I agree that it is hard to tell as the patient sometimes does not know if they have had an AWV previously. We just make sure that the patient signs an ABN so that we can bill them if needed.

You can obtain the patients AWV eligible dates on Novatisphere. Google if you don’t have access. It is a it cumbersome to obtain access but well worth it once you do.

Please note the AWV IS FOR MEDICARE PATIENTS. ALSO HAS ANYONE SEEN ANY LETTERS FROM MEDICARE SHOWING PENELTIES FOR NON COMPLIANCE OF TESTING THE AWV SINCE ITS NOW MANDITORY FOR OFFICES TO PROVIDE AND DO AWV on THIER medicare patients!

I’ve heard letters of warning and PENELTIES are being sent out from medicare and large PENELTIES at that!

Please advise

Julie I had not heard about penalties. Do you have a link from Medicare you can share?

Is there an age restriction when billing AWV’s? Can we bill AWV for a 39 yo?

Amanda —

We have not billed an AWV for anyone under the age of 65 but Medicare does not reference age, only enrollment with Medicare.

“Medicare covers an Annual Wellness Visit (AWV) providing Personalized Prevention Plan Services (PPPS) for beneficiaries who:

— Are not within the first 12 months of their first Medicare Part B coverage period; and –Have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months.”

Just following up…Does anyone know of a CMS site/reference that specifically states G0402/G0438/39 are reimbursable if the visit is done in the patient’s home. Before my employer will create this position for me-they want documentation from a CMS site that it is indeed reimbursable. I have read hours of CMS/Wellness info and cannot locate this specific information. Thanks, Eileen

Naveen – do you know if a CMS website I could reference regarding Medicare wellness visits allowable in home? My organization would like this before proceeding further and performing any visits in home. Thx Eileen

YES YOU CAN

Thanks so much. Is there anywhere I can reference on the CMS website regarding locations they can be done? I am an NP and have submitted a proposal as a new position to do some of these in the homes. Before this is implemented my organization will want to be certain they are reimbursable. I spent hours on different CMS websites yesterday and found NOWHERE that it stated they can’t be done in home but will need a reference point to show that they are allowable in the home. Can you point me in right direction as to where I might find this info? Also… Thanks so much for your prompt response earlier. Eileen

Does anyone know if you can do a Medicare Wellness visit in the home G0438 or G0439

PATIENT IS NEWLY ENROLLED WITH MEDICARE, AND HAD PREFORMED ROUTINE OBGYN EXAM DURING THE OFFICE VISIT, WHICH CODE WILL BE RECOMMENDED

THIS IS VINOTH

Hi Manny, Why does Aetna reject this: on same DOS, 99212 + M17.0, G0439 + Z00.00? Says” invalid information: ICD10; at least one other status code is required to identify the related procedure or diagnosis code”? Non-Medicare patient.

AETNA DOES NOT RECOGNIZE G0439 AS A VALID PROCEDURE CODE. YOU WILL NEED TO BILL PREVENTATIVE SERVICES CODES 99381-99397 ETC.

Hello Manny,

Recently our Connect Care system personnel at our very large Bonsecour Health system has changed the due date for any subsequent Wellness visit (i.e. G0438 after a G0402 or G0439 after a G0438)in Health Maintanence(which shows in a patients chart when preventative services are due) to 335 days (11 months) and sent out a notice that they can be done as long as 11 months has passed. However, when I check the Medicare A/B standard policies for eligibility dates they are giving a 12 month waiting period. I have also been told that Contract Medicare policies such as Humana, UHC, Cigna can be done any time with the new contract year (Jan 1-Dec.31)even if the patient was just done the end of 2015. I am not getting any response from management or connect care so I thought I would write to you if you can help clarify these issues for us. Thank you! Karen, Medicare Wellness RN.

Hello, Recently our office changed billing services. Prior to this change the providers where billing a 99397 along with AWE since they are two separate exams and for the most part getting reimbursed. The new billing service is telling us we cannot do this. Please advise if these two codes can be billed during the same visit and what insurance companies will reimburse for both (I understand straight Medicare will not). Thank you,

Hi Kristi —

You sure can bill for both a 99397 and the AWV. Of course the 99397 would be the patient’s responsibility, as you understand already, but Medicare will pay for the G0439. We have seen a few secondary insurances pay for the 99397 but not many. We don’t keep a list of those as it can change at any time. You can even bill for a problem oriented E/M code such as 99212 if appropriate. –Manny

Hello! I have AWV claims denied due to “Invalid place of service” on Nursing Home patients. I am a rounding physician. Please let me know if you know anything about that issue. Thank you!

Hi there, @Manny Oliverez I have been reading and getting help always by reading your posts. I have few questions if you can please help me. I will really appreciate it.

Question # 1 = If patient is coming in for an office visit for annual wellness visit follow up, what diagnosis code should be billed if doctor has not found any issue in patients lab results or general checkup ? Z00.00 is already been billed for the first visit and paid but I know for sure if I will bill Z00.00 with 99214 insurance will Denny the claim. Please Advise. Thanks

Kind Regards, Muhammad Imran.

Imran when you bill the office visit, you need to look for the other complaints the patient may be having and that diagnosis code should be used as the Primary diagnosis code. This is in case the office visit and the wellness visit are done on the same day.

But sir I have couple of patients who dont have no issues at all but they came for office wellness visit and they were recalled by the Doctors for a lab follow up. I have already billed their wellness visit with Z00.00 Dx code and the claim is paid but their follow up visit is still left and I dont have any Dx code to bill.

Another question if you can please help me on this as well. How can we get paid by Government plans such as Medicare, replacement plans, Hummana Medicaid for 90636 (HepA-HepB) Vaccine & 90715? I have used Z23 (ICD 10) and Admin code as 90471 but they dont pay for it at all yet.

Unfortunately Medicare does not pay for most vaccines.

Naveen, thanks for your help answering questions. We are so busy over here that I find it hard to comment on a timely basis. I sure do appreciate it.

HI MANNY..MY PLEASURE THANKS SO MUCH.. I AM GLAD THAT I HAVE BEEN OF HELP TO YOU..

Imran, if you don’t have another reason like a medical complaint/illness from the patient, you cannot do a followup visit. I would suggest you write it off.

Thanks. and what about my other question.

Excellent ideas

Hello, I am having NO luck billing for wellness visits to Medicare. I just billed a G0438 for a patient who has been with our practice for 3 years but we have never billed a wellness visit. It was denied by Medicare because “lifetime maximum benefits has been met, service already paid once in a member’s lifetime”. WHAT??? so this code is a ONE TIME THING?? Why does Medicare not make that clear and what code do I use instead? Thank you, Kathie

YOU SHOULD USE G0439…G0438 IS ONLY USED FOR THE PTS FIRST VISIT AFTER BEING WITH MEDICARE FOR ONE YEAR….USE G0439 FOR ALL YEARS AFTERWARDS…MEDICARE ONLY PAYS FOR CODE G0438 THE NEXT YEAR AFTER PT IS ENROLLED REGARDLESS WHETHER OR NOT YOU EVER BILLED A WELLNESS VISIT.

Thank you so much for this answer. Is this a new guidelines or has it always been G0438 after 12 months of enrollment/eligibility?

Does anyone know how to bill G0438-G0439, when your a provider based clinic? Do you bill Medicare Part A or Part B?

YOU WOULD BILL MEDICARE PART B. PLEASE VERIFY THE ELIGIBILITY FOR PREVENTIVE SERVICES, BEFORE YOU BILL.

You can always check the Medicare website in the eligibility section. Once in the patients eligibility section there are 9 tabs near the top. The tab on the far right is Preventive. Here you will find a list of when the patient is eligible for different preventive blood work and exams. It is very helpful. If the patient was not eligible at the tos and there is an abn on file, you can bill the patient.

On the day you arrive at the doctor’s office, Does the biller know it’s your annual wellness visit and there is no copayment?

Catherine it has to do with the service the doctor provided, not the biller. The biller can ONLY bill what the exam documentation indicates the services where that the doctor performed.

Now if the doctor indicated on the checkout form when you were done with your visit that an Annual Wellness Visit was performed then the Cashier that collects your co-insurance should know that there should be nothing to collect. When a patient has Medicare and a secondary insurance it is difficult to know what exactly the patient will ultimately be responsible.

Most doctor offices will wait to hear back from all insurance companies to see if they made the patient responsible for and amounts and then send the patient a statement as appropriate.

Does this help?

Can my family practitioner perform the G0438-G0439 to our long-term nursing home patients at the nursing home facility?

YOU CAN BILL THE 99213 WITH THE “X” DIAGNOSIS FOR THE COMPLAINT HE/SHE IS HAVING. THEN ALSO BILL THE G0439 WITH Z00.00

Yes, I am told that you can bill a wellness visit with an E/M code such as 99213. Just add modifier 25 to the E/M code and make sure that the pt was in for more than just the wellness visit and it is properly documented.

Hi, I have a question. I have a patient with “X” complaint today. But he qualified for (G0439) with 99213 there is correct?

Hello I have another question , I have two claims denied with 90715 tdap vaccine . Being denied because insurance said it can’t pay for code because it was done in office . Is there a different code I have to bill for the vaccine given in the office ? Please help !!

In reading the article, Medicare GO438-GO439: Two Annual Wellness Visit Codes, I have a question regarding the HCPCS billing code GO402 which the article says to use for billing an initial wellness visit the first 12 months of Medicare coverage. I understand that to mean GO438 is not a billing code. Therefore, does that mean that there are two codes for each; one billing (GO402) and one for the exam done (GO438)? Could this GO402 on line 13, subtitle: GO4039 Annual………..Subsequent….. Could this be a typo error and should be GO438 (initial exam)? I am trying to learn the proper billing codes and thought that the two numbers GO438,GO439 were the billing codes. Thank you for clearing up my confusion.

Hi manny , Humana is denied three of my claims stating g0438 isn’t a billable code only billed with Medicare , do you know what code I can bill to get my claims paid ?

YOU COULD BILL THE PREVENTIVE E&M SERVICES CPT codes 99381-99397

WE NEED TO HAVE A MORE SPECIFIC DETAIL TO DRILL DOWN INTO YOUR QUESTION WITH REGARDS TO THE DENIED CLAIMS FOR 90715. ITS AN APPROPRIATE CODE, BUT WE NEED TO FIND OUT WHAT OTHER PROCEDURE CODES WERE BILLED AND WHAT DX CODES WERE USED.

Can Home Health Nurses provide G0438 & G0439?

https://www.capturebilling.com/medicare-g0438-g0439-two-new-annual-wellness-visit-codes/#comments

THE DIAGNOSIS IS SPECIFIC TO AGE AND CONDITION VARIES FROM Z00.00 – ADULT Z00.129 – CHILD (ABOVE 28 DAYS)

what are the new ICD 10 diagnosis codes for Wellness exam?

will I get pay for seeing patient for 2 reasons, G0439 and routine check up 99349 on the same date of service? Thanks Tiffany

Yes, you will get paid as long as you have this specific reason for doing the 99349. Make sure you use the appropriate modifiers, like 25.

PLease assist with me how to resolve the issue.

You can only use dx code v70.0 then it will pay.

HI MY CLAIM IS DENIED FOR G0439 CODE STATING NOT COVERED AND I HAVE BILLED THIS WITH DX CODE V72.31, CAN ANY BODY HELP ME HOW TO CORRECT THIS AND GET PROCESS AND PAID.

First find out the eligibility for the patient with Medicare; whether this is a Welcome to Medicare Wellness Visit (G0402), Initial Wellness Visit (G0438 – billed subsequent year after billing the welcome visit), or a subsequent Annual wellness Visit. If the patient is eligible, try billing the claim back with ICD code V70.0 along with the appropriate code as given above.

THIS CODE IS FOR V70.0 DX ONLY THE OTHER IS A WELL WOMAN DX

I need to see a sample EOB OF ANNUAL WELLNESS VISIT GETTING PAID ASAP

Are RVUs assigned to Wellness Visit codes?

Manny, United Healthcare Medicare Advantage program (AARP) is paying for a yearly physical (99397) as well as the IPPE or PPPS codes. We have been told that United will pay for the G0438 and G0439 “once per calender year” and that they don’ require 12 months to have pased. I am concerned that we are being misinformed By United and these will ultimately be denied. Can a Medicare Advantge provider change the policy of providing this preventive service less than 11 calender months from the previous visit? I understand they can add services such as paying for 99397 but I didn’t think they could or would change the benefit rules for the G0438 or G0439.

I would like to know the exact cpt code for Welcome to Medicare exam. Is it G0438. This would be for a patient that just turned 65 and this is her welcome medicare exam. Medicare is suppose to pay for the welcome to medicare exam but it keeps getting denied by medicare.

THE WELCOME TO MEDICARE ANNUAL WELLNESS VISIT SERVICE IS BILLED USING THE CPT CODE G0402. This should get paid because this is the first wellness visit after the patient got her Medicare.

HOW FREQUENTLY CAN A PATIENT AVAIL A HOME VISIT BY THE DOCTOR? IS IT LIKE ONCE PER MONTH? OR IS IT LIKE IN 28 DAYS? COULD YOU PLEASE HELP ME UNDERSTAND HOW FREQUENTLY MEDICARE WOULD WANT US TO SEE THE PATIENTS?

Hi, What if my practice bills G0439 when the patient is due for G0438. If a year has passed since then, am I able to bill at his next visit the G0438 and get it paid by Medicare?

I have been looking everywhere for that questions and I can’t find an answer.

IF A G0438 WAS NEVER BILLED, YOU CAN TALK TO MEDICARE CONTRACTOR AND REQUEST THEM TO REPROCESS THE CLAIM WITH THIS CODE. IF THEY WANT YOU TO SEND IN AN APPEAL/REDETERMINATION REQUEST, THAT WOULD HELP !

Hi Manny: Our Family Medicine Practice is located in Virginia. We currently use LPN’s under the direct (on site) supervision of a physician to do our G0438 and G0439 HCPCS Medicare Wellness Visits. We are considering hiring a Certified Medical Assistant. In Virginia, can a CMA perform a MWV under the direct supervision of a physician (on site but not in the room)? Many thanks, Joe

AN INSURANCE REP IS INSISTING G0438 INITIAL AWV IS ONLY BILLED WHEN THEY TURNED 66 A YEAR AFTER A PT TURNED 65. SO ALL 66 YR OLD AND OLDER ONLY GETS G0439 EVEN THOUGH THIS IS THEIR FIRST INITIAL AWV. IS THIS CORRECT? G0438 IS ONLY FOR 66 YEARS OLD THERE IS NO AGE RESTRICTION RIGHT i CAN BILL G0438 FOR A 75 YR OLD COMING IN FOR INITIAL AWV, THEN G0439 A YEAR LATER.THANKS

YOU CAN ACTUALLY BILL SOMETHING CALLED A “WELCOME MEDICARE AWV”, BILLED WITH CODE G0402. THE NEXT SUBSEQUENT YEAR, G0438, AND THEN FOLLOWED EACH YEAR BY G0439.

What preventive service codes can you bill together with an AWV, when preformed on the same day?

You can bill a Routine Well Check such as 99387 or 99397. Of course Medicare does not cover it so the patient pays out of pocket. Some secondary insurance companies do pay so it may be a good idea to submit the claim anyway.

Here is a link to CMS on some preventative procedures they may cover: http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf

Can you bill TCM codes for a patient that resides in a NH or ALF? Also, can you bill a TCM performed at the patients home?

Can the AWV G0438 be billed at a facility based clinic, or does it have to be billed as an “incident-to”? Thanks

You should have no problem billing the AWV from your clinic. Incident-to rules to not apply to AWV.

Check with your local Medicare carrier for detailed instructions.

Scenario – patient comes in for an AWV (G0439). She also would like to have a pelvic/breast exam and obtain a pap smear for screening. Typically I would bill the G0439, along with the G0101 using ICD-9 V70.0 and V72.31 if they are done the same day. Would this be correct?

Second scenario – Patient came in for an AWV (G0439), wanted a pelvic/breast/pap but provider did not have enough time to do these. If we bill for the G0439 (ICD-9 V70.0) that date of service, can we then bill for just the G0101 when the patient returns on another day for just the gynecological exam, and also use the V72.31?

Hello Manny, Can you bill a depression screen (G0444)and an annual wellness exam together? Or is the depression separately billed?

Hi Michelle if you got a answer for your question, please do share with me

How do we bill for home health plan of care forms that we review and sign? Do you know how much medicare pays for this?

Mary —

There are two G codes we use.

G0180 – Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per certification period.

Medicare National Payment: 41.48

G0179 – Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per re-certification period

Medicare National Payment: 53.99

Check with your local Medicare carrier for their exact billing guidelines.

One of our physicians has a patient who is diagnosed with Guillain-Barré. He sees the family of the patient to discuss the plan of care for the patient. Pt has BCBS and Medicaid. How do you bill for the visits?

karen says:

February 19, 2015 at 3:06 pm

There is some differenc of opinion going on about where to add the -25 modifier. Scenerio #1. If a patient comes in for a cough and it is noted that they are eligible for a G0438; is the -25 modifier appended to the 99213 code or the G0438? Now reverse the scenario #2: If the patient comes in for only a G0438 and then seen by the physician due to say High blood pressure noted on the wellness visit; would the -25 still be appended to the 99213? We are being told that the -25 modifier needs to be appended to the G0438 if they are seen first for a wellness visit and then seen after for an acute visit. In my experience over the past year doing this – we are getting paid only when the -25 modifier is appended to the 99213/4 codes and not the G codes for the wellness visits. Thanks for your help

Karen we do not place the 25 modifier on the G code. We append the 25 to 99211-99215.

Manny – I have just been informed that Medicare is no longer covering Bone Density Scans for screening purposes – (.i.e. postmenopausal women). No more V codes can be used. I do not see any updates in Medicare.gov regarding this. Do you have any information? Thank you so much.

Well that’s not very nice. Currently we do not have any clients doing scans so I was not aware of this. I don’t have any info on this but thanks for letting me know so I can check it out.

Does the HRA need to be completed by the patient or can the nurse fill it out via verbal communication? Does the hard copy of this need to be in the EMR or can it be abstracted and destroyed?

No, the patient does not have to fill out your Health Risk Assessment form. The nurse or medical assistant can ask the patient the questions. The reason we have the patient fill out the form is so that we don’t take time away form the nurse. The nurse’s time can be better used helping other patients.

I would scan a copy into the EHR. That way you have a record in the patients own hand if there are any questions in the future. An abstract with the all the answers covered should be fine.

I would contact your malpractice provider and ask them what is the best practice for this would be.

Thank you, I have another question, let’s say a patient comes into our office for an AWV, she has a Medicare advantage plan that has a $500 deductible that she has not met yet. Durning the AWV she receives a prevar 13 vaccine, is that covered or does she have to pay because deductible hasn’t been met yet?

When a nursing home patient is seen primarily for L4 S1 decompression/fusion, can we use V45.4 as the primary diagnosis? If not, what is the alternative code ?

Our practice sees patients in their homes using procedure codes 99342-99350. Could you provide me with the Medicare approved extended visit code for an extra 30-60 minutes of services in their home? Also, can you bill a Welcome to Medicare Visit (G042) or G0438/39 along with the above procedure codes (99342-99350)?

Thank you for all your help.

Carleen —

CPT code 99354, Prolonged service in office or other out patient setting 30-74 mins, is an add-on code that would be appropriate with the proper documentation. Medicare reimburses about $111 depending on your jurisdiction.

I don’t see why would would not be able to bill a Welcome to Medicare or an Annual Wellness Visit along with your other E&M codes as long as you perform all the elements required. You could even bill a routine physical exam 99397/99387.

Of course it is not covered by Medicare but some secondary insurance companies may pay or you could bill the patient directly for the physical.

No need for an ABN for the physical but I would get a voluntary one anyway jut to inform the patient that they may be responsible in the end.

When billing a wellness visit and an injection is performed, cpt 20551, what modifier should be used?

Lynn you should not need a modifier with this code.

If patient was with Dr A in 2013 and Dr A performed and billed initial AWV G4038. In 2015 the patient changed to Dr B. Dr B is not sure if the patient has ever had an AWV and patient forgot. Which code should Dr B bill?

Sarina if you were to unknowingly bill a G0438 becasue the patient had one previously, Medicare would let you know by denying the claim. You would then rebill will the G0439.

Sometimes patients do forget they had an initial AWV. No way to know for sure unless you have the old medical records.

Also don’t forget to get an ABN signed incase you have to bill the patient.

Does anyone know if the Medicare Replacement plans are covering Zoster or Tetanus vaccines in the PCP office now – Original Medicare A/B requires them to be given at the pharmacy. Thank you.

Karen we have not seen them cover the vaccines.

We administer the vaccine and order the medication from the pharmacy. You will only get paid for the administration b/c Part D was billed for the medication

I am getting a denial for 99387 being billed with G0439, which is the correct way to bill for this?

Edna you will always get a denial from Medicare for 99387 as Preventative Routine Physical Exams are a non-covered service.

The reason to bill Medicare is to get the denial and have it then sent to secondary to see if they will pay the 99387. Some secondary insurance companies do.

If the secondary does not pay you can and should bill the patient.

I’m curious. Does the 15% reduction for NP apply to the AWV or does it pay at 100%?

Jennie Medicare will always pay NPs 85% of the allowable, even for AWVs.

CAN WE DO AN ANNUAL WELLNESS VISIT AT A PATIENT’S HOME, AND BILL IT WITH 12 POS?

Yes, we have practices that do that and we use POS 12.

How or can I bill for 90715, 90471, and G0438?

Edna —

In general billing other CPT codes with an Annual Wellness Visit is OK.

You can bill a physical, 99397, or a problem oriented visit, 99211-99215, and that would be fine.

Can G0438 and G0439 be performed in a patient’s home or in a nursing facility?

Yes Rochelle you can perform the Annual Wellness visit at those two places of service.

do you have any references stating it can be done in the home?

ROCHELLE HAVE YOU SEEN ANY DENIALS WHEN YOU BILL THE CLAIMS WITH POS 12

Manny – do you know if MUTUAL OF OMAHA – PLAN F (MEDICARE SUPPLEMENT) [33347] will cover a physical code 99397?

Karen as you know all insurance policies are different so I can’t say if the patient has coverage.

I would call Mutual of Omaha and give them the code to see if they offer coverage for a physical. But even then I would not trust them. They are an insurance company after all. LOL

The best you can do is tell the patient that you will submit the claim and see what happens but that they may be ultimately responsible. Give the patient the option to have the service or not.

Don’t forget when talking about Plan F that it is a Medicare Supplement. Doesn’t matter what Company sells it, because an F is an F & the coverage is “Supplementing” Medicare. Therefore, if Medicare doesn’t cover something, the Supplement, in the case, Plan F won’t cover it. Medicare is the gatekeeper of decision making on approved procedures to begin with & if it’s not a Medicare approved procedure, the insurance company will never pay it.

What Diagnosis code do I use if the patient has the 99397 and the G0438 or G0439 done on the same day.

We currently use V70.0 which is utlized for a CPE (compelete physical) and V70.0 also is used for an Annual wellness visit if we are combining the visit into one encounter and using the modifier 25 – But if we want this to be two separate charges, is it ok to use V70.0 on both separate encounters?

Karen use V70.0 for both 99397 and G0438/G0439. No 25 modifier is needed. If you do a problem oriented visit on the same day, a 99211-99215, then append a 25 modifier to the sick visit. You can bill for all three codes.

99397 & G0438/G0439 are preventive visit only. We are using G codes becoz of medicare.

99397 & G0438/G0439 are preventive visits only. We are using G codes becoz of medicare.

Manny, I am just wondering if once a Medicare Supplement policy has been billed a AWV code; will the insurance also pay for a 99397 within the same 12 months? I have called some supplemental policies like UNC-AARP Medicare Solutions and they are covering #99397 and the MWV G0438/G0439?

For instance, we have several patients that are getting covered for CPE (annual physicals) through the Medicare Supplemental programs; can they also have an AWV by the Nurse Specialist doing the AWV’s in the office after seeing the physician? An if so, Does it have to be two separate encounters?

Thank you, Karen

Karen, yes you can bill both the CPE and the AWV on the same visit as they are two different services. If the patient has coverage for a 99397 both should be paid. Several of our practices do just that.

Of course some supplemental policies don’t have coverage for the 99397. In that case we bill the patient directly after we see if the secondary pays.

Thank you! Are you aware of which Medicare supplemental policies do not cover both services? I know any standard Medicare A/B package does not cover 99397 and therefore we are doing the MWV with modifier if they see the physician as well for a routine visit. However, many Medicare patients are coming in with the newer replacement HMO/PPO plans that do cover 99397 which is great!

Thank you! Do you have a list of which Medicare Replacement programs will cover both the 99397 and Wellness Codes. G0438/9?

Also when is it necessary to use the GY modifier?

Thank you Karen.

Wondering if anyone has a list for Medicare Replacement Plans that cover both the 99xxx (annual physical) and Medicare AWV Wellness Codes (G codes). I know states/counties/plans are different but a starting place would be great.

Manny – With a Medicare Cost Plan such as Rocky Mountain HMO, with Medicare being secondary, can you use G0439, or are they wanting a preventive charge such as 99397? Sometimes the provider uses a V70.0 ICD-9 code with their AWV and other times when providers are doing an AWV, they only put in codes such as 401.1, 496, etc. and do not use the V70.0(per Medicare guidelines stating “no specific diagnosis code”. Billers state the claim was denied when using the G0439 and want me (data entry) to change the code to 99397, that they don’t recognize the G-code. A bit confused with Medicare Cost Plans which code they are wanting? Can you clarify this? If the V70.0 diagnosis code is used, is this confusing the billing process?

Hello Carolyn —

Yes Medicare does say “no specific diagnosis code” is associated with G0438 or G0439 but we find that they do like V70.0 which is the ICD-9 code that is used by all our practices.

The problem with changing codes is that a 99397 is totally different than an AWV. If the provider actually performed an AWV then the documentation will not match a 99397.

Check with the carrier on exactly how they want Annual Wellness Visits billed. Hope this helps.

Hey Carolyn, I’ve been billing for my doctor for a few months now and I have noticed claims gotten paid with v70.0 as the primary dx and also with specific dxs. Also, HMO plans replace medicare, so medicare does nothing as secondary. Finally, make sure what is the patient’s effective date with the insurance maybe he/she is due for their welcome to medicare visit (G0402) or maybe is the G0438 if they have never gotten a wellness visit before. Either way your best bet is to call the insurance and ask a representative to help you verify eligibility on CPT codes and give them the 9939_ and the G0439 to see what they say.

Hope it helps!

Such plans like WellCare, Careplus healthplans are they utilizing G0439 G0438? It appears like these plans are hit and miss. It gets frustrating. What do we bill, G codes or other preventative CPT codes?

Kelly when we bill AWVs to Medicare Advantage plans we use the G codes. There is really no preventative care code for an AWV alone.

Hi Mr Oliverez,

Here in my doctor’s billing dptm we do a 99214 with a modifier 25 plus a Gcode and both get paid. We however use v70.0 as the primary and only dx for the Gcode, or we use the same specific dx we used for the 99214 for the Gcode too and it gets paid as well.

*Important thing is to use the modifier 25 in the 99214 in order for both to get paid.

I am thoroughly confused about the AWV WWV and preventive visits. OB-GYN practice. please help.

Do you use V70.0 with G0438, G0439 and G0402?

Kelli we typically use V70.0 with the AWVs and Welcome to Medicare Exams.

I am still not sure:

If a patient is new to me but not new to medicare:

Do I bill G0438 automatically ( assuming they already had their welcome to medicare exam) or do I need to find out if they already had a G0438 and then bill a G0439?

In other words is a G0438 a once in a lifetime code or a once per a doctor code?

once in a lifetime after their first 12 months of being enrolled with Medicare.

Example: patient’s Medicare eligibility started in 11/20/13 and today is 11/18/14 and you are going to bill and submit claims today you are still able to bill a G0402.

Example 2: patient’s Medicare eligibility started in 11/10/13 and today is 11/18/14 and you are going to bill and submit claims today you are still able to bill a G0438. then next year in 11/18/15 you would bill G0439 only every eligible year.

HI can you please help me with this scenario

Patient is here for G0439 and vaccines Q2037 and 90714. I know I have to use G0008 admin code for the flu but what would I use the TD admin? 90471 or 90472?

Chantal this is the way I would code the scenario:

G0439 90714 with 90471 Q2037 with G0008

Medicare does not cover 90471, so unless the patient has a secondary insurance that will cover it, it may end up being patient responsibility.

Hope this helps — Manny

Mr. Oliverez, How would secondary cover 90471 when Medicare initially writes it off (96 : Claim not-covered charges &M16)? Am I even allowed to go after patient for it if I have ABN? In one encounter I had G0439 90714with90471 and99214-25(dx: ulcer) and Medicare only paid for AWE and the level 4 visit. Basically TD vacc and the admin denied. How they expect providers to update pt with their imunization, admin the inj and then don’t get reimbursed for it?

Mahdi —

Since you stated the patient came in for an AWV and had an ulcer I can only assume that there was no injury. The tetanus vaccine is only covered when there is an injury otherwise it is considered a preventative immunization that is no covered.

Medicare considered the vaccine preventive and thus denied the claim.

You do get reimbursed for the vaccine…..by the patient. Just bill them. No ABN needed since this was a non-covered service.

I appreciate your response. Thank you

Can we say that documentation requirements for preventive services 99391-99397 are the same as G0439?

Louie, the documentation for the AWV is totally different than for routine preventative services. If you do not have the proper documentation for the G0439 it is not billable.

We are not getting paid for out Wellness G0438 codes, do we need a modifier?

Sunny, no modifier is needed. The code should pay with no problem. What denial code are you getting from Medicare.

Can we legally bill a G0101 visit without the Q0091? Just want to know because there is confusion in our office whether or not we can bill the annual well woman gynecological exam without doing a pap smear on the patient and whether or not Medicare will pay the G0101 if we don’t include the Q0091. Please help and let me know where I can find documentation on CMS.GOV or another reputable site.

Thelma —

You should have no problem billing a G0101 without a Q0091. You are billing G0101 because the provider performed, and documented, at least 7 of the 11 elements of a Pelvic and Clinic Breast Examination.

The pap smear does not need to be be done if it is not medically necessary. But if you do the smear, then it is appropriate to bill Q0091. If you look at the code descriptions you will see what each code includes. We have billed G0101 to Medicare for our OBGYN/Family Practice clients with no problems.

There should be more information on the topic at http://www.acog.org and http://www.aapc.com both of which should reference CMS.

Can you bill an office visit e/m code just for the V70.0 to Medicare? The problem I have is when we bill the preventive 99395 to Medicare it deny as non-covered, but the patient has Ohio Medicaid as secondary and will only pay the V70.0 if it is billed as an e/m office visit. most of the Medicaid secondary plans to pay for patient’s over age 20 for the annual visits. Could I use a modifier for Medicare to deny claim to bill to secondary for the 99214, 99215?

Hello Maria —

No you cannot bill a problem orient office visit E/M code with V70.0, preventative care diagnosis, to Medicare. I am not familiar with the billing requirements for a physical with Ohio Medicaid and if they allow or want you to change the CPT code to a problem oriented E/M code. Just make sure you follow their guidelines to the letter.

I do know some secondary commercial insurance companies do pay for the physical after Medicare denies it without changing anything. If the commercial secondary does not pay we would bill the patient the full amount since it was a non-covered service. There is not a modifier to use in this case.

Sorry but I don’t think I am of much help to you in this case. –Manny

Mr. Manny, I worked at primary care physicians, we billed Humana for Annual Wellness (G0438) and Office Visit Charge (99213/99214) and got paid last year and this year. Upon review, they retracted payment for G0438 for this year for denial reason that it is only paid once a year. reading your blogs/, now i understand that we should be using G0439 for subsequent Annuall Welness. If I corrected and resubmit the claims- could we get paid back for those dates/claims they’ve already retracted???

Marisa that is correct. G0438 is only ever billed 1 time. The first time you do an Initial AWV you bill G0438. At year 2 and every year thereafter that you bill the Subsequent AWV, G0439. G0438 is only ever billed 1 time. You should get paid for those once you submit a corrected claim if you don’t go beyond the timely filing limit. –Manny

Hi Manny, Is there a documentation “Shortcut” for subsequent annual visits. For example, we have a unique 3 page form for our sAWV (HRA, sAWV, & Personalized Prevention Plan). Once done, next year there is often very little variation. Rather than rewrite all 3 pages, can we just update last year’s sAWV form and date it effective 11/14/2013? Would that suffice for an audit.

My understanding is that at the subsequent AWV G0439 you would just update the patient’s medical and family history, provider list, get new vital signs and weight, identify any cognitive impairment, update the screening schedule and risk factors list and provide advice. As far as what specific documentation would suffice for an audit, the more the better. I always encourage our doctors to document well especially with Medicare. I would make a new chart note referencing the initial AWV and documenting any updates. I would also initial, date and mark as reviewed the initial AWV visit, G0438, as a cross reference to the current visit. Check with your local Medicare carrier on their requirements.

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Manny, Can I perform annual physical 99397 during a subsequent visit, after AWV visit? Please clarify.

Yes Latha you can bill a subsequent AWV, G0439, with a 99397. Make sure your providers document well and collect the payment for the 99397 from the patient less any carve-outs required by Medicare.

Manny As I explained before we have a digital instrument to produce that AWV on the field ,the instrument will generate a REPORT of the outcome containing the beneficiaries answers to the questionnaire signed by the patient and the licensed professional that performed the interview. In our case the AWV is ready to be billed with the GO 438. Now our system few day later will generate a complete digital Report of all the Health Risk finding and will generate also a TEMPLATE of the PPP requested that will easily assist the physician to prepare his PREVENTION PLAN and discuss it with their interviewed patient. WE plan to bill the AWV / GO438 as soon the visit is performed supported by the INITIAL generated report. Few days later when the OUTCOME OF THE AWV IS PROCCESED AND SCORED AND THE DIGITAL Prevention plan is finished and reviewed by our Prevention counsel the physician will bill a Prevention physician visit (99 code) and if is necessary WILL BILL any required Prevention Code in according with the outcome of the Health Risk factor finding, in order to achieve what Medicare want an adequate Prevention intervention with the AWV/HRA . I will like your valuable comment Thank you

I have a question, can you bill G0438 and 90732 G0009 together or is it bundled for Medicare?

Christina, yes you can bill for the Pneumococcal vaccine and the admin code with the Annual Wellness Visit. Make sure your provides document the AWV properly. Check with you local Medicare carrier for their billing requirements. Hope this helps. –Manny

Would you put a mod 59 on the 90715 vaccine in this scenerio?

G0438 99202-25 90715 90471

Marcy a modifier is not needed with the vaccine but if this is a Medicare patient I don’t think it will be covered. –Manny

Perfect! Thanks for getting back to me. Another thing, if they have a G0402, and a procedure of say, wart removal. Should you add a 25 to the G code? I wouldn’t think so because it is technically at HCPCS code, not a CPT code. What are your thoughts? Am I on the right track? I can’t find anything online.

Good questions Marcy. Typically we would add a 25 modifier to a problem orient visit that was coded with a G0402. For example:

G0402 99213-25

In your wart removal example I would put a 59 modifier on the removal. Now that said, insurance companies and your local Medicare carrier may have their own rules on how they want something billed. Best to check directly with them to find out how they want it billed.

I know, not much help but there is one set of rules for proper coding and another set of rules that each insurance has on how they want a claim coded for payment.

Dear Manny Our companies AWVRESEARCH&MANAGEMENT I CONTRACT WITH INTELLIGENT HEALTHCARE SOFWARE developed an unique digital HRA/AWV software tool that contain a battery clinical validated battery of test that strictly follow the CMS outline of the AWV/HRA. As its expressly mean HEALTH RISK ASSESSMENT our interactive program will be able to provide a comprehensive REPORT of the OUTCOMES indicating the HEALTH RISK FACTORS finding quantitative and qualitatively measured. The way how we selected the HEALTH TEST was trough a long year of SYSTEMATIC REVIEW of more than 5,000 clinical & credited test that fit on the AWV guideline. As you can understand our AWVQ1 proprietary digital tool will be a valuable component that a physician will have to perform the mandated AWV/PPP in compliance with regulation and effectively have a PERSONALIZED PREVENTION instrument that contain GLOBALLY an accurately all the possible HEALTH RISK that a patient may have. We been following since early last year your site and I came to the conclusion that will be worthy to have a meting with you to explore the possibility of getting your technical advice & assistance for our prospective medical professional clients in order to prevent any billing mistake when billing the GO438 or GO439. Please send me an email how to contact you and talk further about the idea. Thank you Dr. Edgar Hoffman COO

Do you know if there is a code for a male rectal pap smear? i have used q0091 and 88160 but they keep getting denied due to sex not consistent to procedure.

Manny, My docs are wanting to know about exact frequency of wellness exam for MCR patients. If patient had an exam in July 2012 and they want to get another one in May 2013, will that deny G0439 for frequency because we billed G0438 the year prior? Does MCR patient have to wait exactly 12 months or does it go by new calendar yr?

Ilona you can bill the AWV once every 12 months. If the patient had an AWV on July 31, 2012 they would not be eligible until August 1, 2013, one year and one day later.

You are using the word “EXAM”. Are you giving the patient a physical exam?

I am so angry! I am disabled, and they now bill for the room and the doctor, almost double the charge! I cannot afford to see my doctor, and cannot afford a supplemental insurance! What the heck is going on? The billing dept., said anything to do with government charges, they have to bill you this new way! This government is hurting the ones who cannot afford it!!

Robin, yes there are very strict rules on billing Medicare and Medicaid and how to bill the patient. I think it will only get worse. With commercial insurance we are seeing patient paying more and insurance companies covering less.

I read that you mention that commercial insurance cant be billed for G0438 why is that? Why would they be paying for this code if it was not allowed? Some of the Doctors I work with have been sending them to all insurances and they all pay for them.

Andres —

So you have commercial insurance carriers that are not part of the, say Aetna, Cigna, United Healthcare Medicare Advantage Plans, or Medigap secondary payers? Which primary commercial plans are paying for G0438 if Medicare is secondary?

Blue Cross and Blue shield is paying for it.

Which BCBS? What state are you in? It’s not am Medigap BCBS policy? Tell me more please.

Florida not a medigap policy.

Our office was told b/c we are OB/GYN we don’t meet the qualifications to bill out G0438/G0439? Our docs have always done preventative and routine exams can you clarify?

Rose —

Not sure who told you that OBGYN physicians could not bill for an Annual Wellness Visit but here is some info from Medicare.

MLN Matters® Number: MM7079 Revised Related Change Request (CR) #: 7079 Related CR Release Date: February 15, 2011 Effective Date: January 1, 2011 Related CR Transmittal #: R138BP and R2159CP Implementation Date: April 4, 2011

Who is Eligible to Provide the AWV with PPPS? • A physician who is a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Social Security Act (the Act); or, • A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act); or, • A medical professional (including a health educator, registered dietitian, or nutrition professional or other licensed practitioner) or a team of such medical professionals, working under the direct supervision (as defined in CFR 410.32(b)(3)(ii)) of a physician as defined in the first bullet point of this section.

Do some more research by contacting your local Medicare carrier.

Hello I’am getting a denial on my code G0438 with a 99214. Can we bill these together I have a modifier 25?

Margo yes you can add modifier 25 to your 99214 . The two codes should pay.

If you do a routine physical exam along with the G0438 and the 99214 , that should pay too. Check with your local Medicare carrier for specific rules in your area.

Getting G0439 denials this year with V70.0. Tried to be creative 🙂 looks like sticking to 99213 or 99214 is wise this year. Do you jave the same issue? How did you go past it?

Sue I just talked to some of the team and they said they are not having any problems with getting G0439 paid. Looks like you have something odd going on there.

We have had success billing G0439 with an Annual Routine Physical, 99397, with the occasional 99212 thrown in for a problem and got paid for all three on the same date of service.

I would be careful with billing a 99213/99214 as a AWV as those codes are for problem oriented visits.

What was the actual denial you got from Medicare?

How did you get paid for the 99397 from Medicare they dont accept those codes? If g0439 is only to be billed to Medicare then 99397 should not have been paid in that Date of service? Thank you

You are correct Andres that Medicare does not pay for a 99397 Annual Preventative Medicine Exam (or routine exam) . But you can make the patient pay for the 99397. You don’t even need an ABN but I would recommend using one just to let the patient know they are responsible financially prior to the service.

Remember a G0439 is NOT a routine exam . If you do a routine exam then you should bill 99397.

An AWV is a wellness visit. The patient and doctor goes a series of required elements as listed below:

– Medical and family history – List of current medical providers – Height, weight, BMI, BP and other appropriate routine measurements – Detection of cognitive impairment – Review risk factors – Review of functional ability – Establish a written screening schedule for next 5-10 years – Establish list of risk factors – Provide advice and referrals to health education and preventative counseling services – Other elements as determined by the Secretary of Health and Human Services

Note that there is no mention of a physical exam because the AWV is not a routine exam as those are not covered by Medicare.

Medicare allows you to bill for both a annual preventative medicine exam and the G0438 or G0439.

If the patient is sick on the date of service you can even bill an E/M code for that service. The codes billed may look like this:

99397 G0439 99212-25

Yeah it helps thank you very much

Thank you Andres!

Is there a good way to explain to our Medicare patients why they get billed for the well woman exam ($80.00). They keep saying that they are calling Medicare who is telling them that our billing dept. should call them because we are coding it wrong (99397) and we need to change our code. They sign the ABN form when they come in and it states that the $80.00 is a non-covered charge and they will be liable but they are still not getting it. What would you advise I say to them.

Debra — There may be some confusion in terminology by your patients. A Well Woman Exam (also known as a Breast and Pelvic Exam) G0101 and Pap Smear Collection Q0091 are covered services from Medicare. A Routine Preventative Medicine Exam 99397/99387 (Some call it an Annual Physical) is not covered by Medicare and does not even need an ABN.

Download our Billing Well Woman Exams to Medicare report. It will explain in detail how to bill for this exam and I believe it will give you information so you can come up with a script and possibly even a handout to explain to your patients how Medicare and the patient will be billed. The carve-outs tend to be tricky to patients.

CLICK LINK TO GET REPORT: https://www.capturebilling.com/download-free-billing-a-well-woman-exam-to-medicare-special-report/

Please let me know if this has been helpful or if you need more info and $80 is cheap – Manny

I have question about, how should we bill G0438, G0101 and Q0091 on the same day.

Where as G0438 is link to Dx code V70.0, G0101 and Q0091 is linked to V72.31. Whether we will get all the procedure paid or do will get denial as maximum benefit exhausted.

I found this in Medicare Well women exam website stating:

Question: Can you bill an annual with a V72.31 Annual Gynecological Exam diagnosis and get paid separately? No. If you have already billed out an annual in a given year (V70.0) then you cannot charge another annual with a different diagnosis.

So, it’s quite confusing how to bill to Medicare insurance. In one of the claim we billed G0438- 25 modifier for DX:V70.0 and well women exam G0101 and Q0091 for dx: V72.31 and we received the payments for all the procedure.

Can you please guide us, how we are suppose to bill two annual for same DOS. As you have mentioned we shouldn’t append 25 modifier for G code.

Kavitha —

I wrote a blog post that covers your question. Check it out.

https://www.capturebilling.com/medicare-billing-well-woman-exam-g0101-q0091/

I also have a report I wrote that explains in more detail how to bill Routine Physical Exams with well woman exams to Medicare.

You can get that report here:

https://www.capturebilling.com/wp-content/uploads/2015/06/Capture-Billing-Well-Woman-Exam-G0101-Q0091.pdf

Hope this helps!

I’m new to billing and I’ve been trying to get paid for the G0403 with the G0438. They will pay with the g0438 with dx V70.0, but they won’t pay for the g0403 with dx v70.0. So I refiled the G0403 with a medically necessary dx 414.01 and they still denied it. Help, am I doing something incorrectly?

Tyeisha, a routine EKG is a once in a lifetime service that must be furnished with the Welcome to Medicare Visit G0402 and cannot be done more than 12 months after the effective date of the patient’s enrollment into Medicare Part B. You will not get paid in the scenario you described above because a routine EKG is not a covered service. Basically you performed a free service and it needs to be written off per your Medicare remit. Sorry.

Medicare only pays on EKGs if they are medically necessary with the appropriate problem oriented diagnosis code.

So you cannot do routine EKGs on Medicare patients per the government. –Manny

Hi Can we bill G0438 for non medicare patient like for UHC patient. Also does this service specific patient’s age. Please let me know

Saifee G0438 can only be utilized for billing Medicare patients, who are typically 65 years and older. The Annual Wellness Visit G codes cannot be used for commercial insurance.

Please keep in mind that when billing G0438, there are key components which are required in order to be properly reimbursed by Medicare and are as follows:

• Taking the patient’s history • Compiling a list of the patient’s current providers • Taking the patient’s vital signs, including height and weight • Reviewing the patient’s risk factor for depression • Identifying any cognitive impairment • Reviewing the patient’s functional ability and level of safety • Setting up a written patient screening schedule • Compiling a list of risk factors • Furnishing personalized health services and referrals, as needed

Subsequent annual wellness visits, G0439, require that all the components above be updated and the doctor must also provide health advice to the patient as needed.

Also remember that an AWV is not a Routine Physical Exam which can also be performed and billed to the patient.

Let me know if this helps –Manny

Thank you so much for sharing so much information on this complicated subject! As of today, we are receiving numerous take backs from Medicare for our Annual Wellness visits because the patient either had lab tests, xrays, or and EKG on the same day. They all were paid by Medicare at the time they were submitted, however, now they are taking back their monies on the AWV. I read the MLN CR 8153 and they stated they are taking back their money. I am not sure why they would on these types of visits? Has anyone else had this happen lately?

We have been billing a lot of the Annual Wellness visits G0438 and G0439 (dx: V70.0). We have also been doing an Evalualtion & Mgmt code 99213 with diagnostic codes with either of these visits, using a modifier 25 on the E& M code. But we have had deniels on the Depression Screening (G0444, dx: V70.0). We have tried it without a modifier and have resubmitted with 59 modifier on this code, also denied. Any suggestions for payment of the Depression Screening?

Is G0438/9 billable with pos 12?

Alex if you look at MLN Matters Number MM7079 there are specific guidelines to billing for a specific place of service (POS) but there looks like there is no exclusion as to where the Annual Wellness Visit may be performed. I did find one reference from the University of Washington Physicians that actually gave the following POS codes that should be fine: 11, 12, 13, 22, 23, 71, 77, or 85.

Check with your local Medicare carrier for their billing requirements –Manny

Medicare HMO “SUMMA” is denying G0438 code & asking us to use equivalent code. What could be an equivalent code ?

WHAT? Equivalent code?

Could Medicare mean G0439? Maybe. Could Medicare mean G0402? Maybe. Could Medicare just be crazy? Probably.

I ask some of our billers if they have ever had a denial like yours Anand and no one had.

Sounds like Redetermination time. Let me know if you find out more information on the denial. –Manny

We had a patient come in for the AWV, the patient also has hypertension and needed refills on meds, so an office visit was also billed at that time with a modifier 25. The physician also did an ear irrigation at that visit, code 69210. We were paid for each of the lines but now the medicare replacement insurance is trying to recover the amount paid on the well visit stating that it should not have been paid within the global period for CPT 69210. Should we have attached a modifier to the G0439 code?

Colette when 69210, removal of impacted cerumen (separate procedure) 1 or both ears, is done with another procedure/service I would append modifier 59. The G0439 does not get a modifier. You will need to appeal that claim. Just going by what you wrote above the claim may look something like this:

G0439, V70.0 99212-25, 401.1,V68.1 69210-59, 380.4

Actually 69210 must have modifier AG to be paid and a DX of 380.4

Deanna does Medicare in your jurisdiction require you to add the AG modifier to indicate Primary Care Physician?

Alot of problems with medicare. Numerous claims being denied. When you call medicare you get put on hold and shuffled around. No one can seem to be able to answer any questions.

I come across this blog on most searches I do on the AWV. I appreciate that you were on top of providing billing information and advice to physicians so quickly after the AWV became an option for physicians.

Thank you David. We are still educating doctors. Most providers I come across believe that a AWV is a full routine physical. I have another presentation next week with a large Family Practice to help train the physicians on the differences in the two services and how to document the AWV properly. I think i need to write a more detailed post. Thanks again –Manny

My Dr billed me for a office/outpatient visit on the same day as my wellness visit (which they coded wrong I found seen seeing your website) are they allowed to do this?

Elizabeth, yes a provider can bill both an office visit and an AWV on the same day. They are two separate services with different documentation requirements. Medicare should pay for both services if billed properly. –Manny

Will Medicare pay for G0439 and 99213 in one office visit?

Medicare should pay for both codes since they are different services. Make sure you have separate documentation for each service. Check with your local Medicare carrier for their billing requirements and the type of documentation needed especially for the G0439 Subsequent Annual Wellness Visit.

Thanks for your question Pam –Manny

By 12 months between the visits does it HAVE to be exactly 365 days or can they be seen for subsequent wellness visits if it’s within a week of their previous visit? How strict is the whole 12 month thing? We have just a few of our patient who have been scheduled for subsequent visits just shy of the 365 day mark. For routine annuals this was never a problem…

Kamara it has been our experience that if they say one year and you send in a claim that is only 364 day from the last visit that it will be denied. If it was my practice I think I would reschedule those patients for the following week to make sure the claim is not denied due to time limits. You are correct that for the routine annuals this was never a problem because those physicals (99387/99397) were and are still not covered by Medicare. So a patient could have two or more a year because it is a non-covered service that the patient is by statute responsible for. Remember if you are performing a Routine Annual Physical and an Annual Wellness Visit you are able to bill for both since they are two different services.

Manny can OB/GYN practice use the G0438 and G0439 codes?

Elizabeth take a look at MLN Matters Number MM7079 . This Medicare publication tells you the Providers that are eligible to perform a G0438 and G0439. Below is an excerpt from that publication. Looks like OBGYNs are OK.

— Manny

The provider must be the Primary Care Physician though or else someone isnt' getting paid and claims will be duplicated or more between various offices. If a patient has a PCP and sees the OB/GYN for the bi-annual Pap then they should not be coding for the AWV. These should be done by the PCP and not the specialist. We are having to appeal a situation right now and the specialist office coded for the AWV last year. We did not know coded for their AWV-initial and our visit is being denied. Medicare specifically asked the patient who was PCP and did the specialist go through certain questions. PCP did but specialist only saw them for the specialty issue.

We will be doing an annual routine physical exam for this patient and the coding that we are planning on using is 99335-25 G0439 for the cpt we have dx code V70.0 for the g0439 and 472.0, 401.9, 438.85 for the 99335

You would need to bill the appropriate Annual Routine Physical Exam that you are doing with the appropriate code such as 99397 with a V70.0. You did not say you were doing an Annual Wellness Visit so you should not be using G0439. If you are also doing an Annual Wellness Visit (Subsequent) in addition to the Annual Routine Physical Exam you can bill for both. The applicable diagnoses for 99335 should really be the medically necessary diagnoses – not the V70.0 since 99335 is for a problem oriented visit in a rest home.

Based on only the information provided, and if you are also performing an AWV, I think this is what you may want to look at billing to Blue Cross and then to the Medicare Secondary:

99397 V70.0 99335-25 472.0, 401.9, 438.85 G0439 V70.0

Please be sure that the documentation requirements are met for all services provided and check the coding guidelines of the carriers. Also remember that Medicare does not cover Annual Routine Physical Exams so if BCBS holds the patient responsible for a copay or co-insurance, bill the patient. — Manny

Manny if a patient has BC/BS as primary and Medicare as secondary could we possibly bill out the G0438/G0439 code?

Pauline what are you doing at the visit, an Annual Wellness Visit Exam or a Annual Routine Physical Exam or both?

Please help me identify the following cpt coding for: 1) DepoMedrol 20mg 2) DepoMedro 40mg 3) DepoMrol 80mg. 4) Does the injection code 90471 apply?

Thanks, Mirna

The codes for Depo-Medrol (methylprednisolone acetate) can be found in the current edition of the HCPCS Level II coding book. Look at Appendix 1 – Table of Drug and Biologicals to find Depo-Medrol in the alphabetical listings. There you will find the drug name, unit, route and J code. Once you have the J code find the description in the Drugs Administered Other Than Oral Method section of the coding book. Make sure that the description matches what you are giving the patient.

J1020 Depo-Medrol 20 mg J1030 Depo-Medrol 40 mg J1040 Depo-Medrol 80 mg

CPT code 90471, immunization administration, does not apply in this case because Depo-Medrol is not a vaccine. A better code to use would be 96372 , Therapeutic, prophylactic, or diagnostic injection, subcutaneous(SQ) or intramuscular(IM).

Hope this helps. –Manny

We have a situation where we are trying to figure out how to bill a NP to our office, but not new to Medicare. The PT has already had their welcome to Medicare exam G0402. We are trying to decide if we should bill with G0438 or G0439. Logically, I believe we should bill with the subsequent. But with this PT being new to the office, that is where I am getting thrown off my train of thought. Please help.

An Annual Wellness Visit is not subsequent to the G0402 , Welcome to Medicare exam. Billing a G0438, Initial AWV is appropriate. You should not bill a subsequent AWV without the initial. I know you said logically but this is Medicare. And remember that an AWV is not a Routine Preventative Exam so if you perform a 99387 and document it you can bill the patient. Both can be done on the same day. Check with your local Medicare carrier for detailed information on billing these visits. Hope this helps –Manny

If a patient see their physician for their once in a life time IPPE Initial Preventive Physical Exam and 12 months later come back to see their physician for their AWV (Annual Wellness Visit), do we bill the initial G0438 (first visit, once in a lifetime visit) or do we bill the subsequent visit of (G0439)?

Lori you would bill the initial AWV G0438 since the patient has not had an Annual Wellness Visit previously. The following year you would bill G0439. –Manny

Hi Manny, I got confused a little. Patients is eligible for AWN G0438 ONLY in the second year of Medicare coverage? or during the lifetime as long as 12 month has passed since IPPE ( if pt is eligible) and AWN has not been billed before. For example if patient has Medicare Part B effective on 01/01/2003 and was never billed for AWN G0438 before, can I bill G0438 for 2011 visit?

Irina thanks for your question.

The G0438 Annual Wellness Visit can be billed out at any time if the patient has never been seen for the AWV and it is after the first 12 months the patient became a Medicare recipient. For example, if the patient has had Medicare coverage since 2009 but the AWV has never been billed then use the G0438 code, not the G0439 Subsequent visit (as there was no prior G0438 for the G0439 to be subsequent to). There is no time limitation to the G0438 unlike the G0402 IPPE ("Welcome to Medicare" exam) and it’s corresponding once in a lifetime benefits.

As always please be sure to check with your MAC and the guidelines at CMS

Hope this helps –Manny

(con't from previous comment) I did a little research and discovered the following on the Medicare.gov web site under "Welcome to Medicare Preventative Visit" where it discusses "Your costs in Original Medicare": "You pay nothing for the yearly 'wellness' visit if the doctor or other health care provider accepts assignment. If you get additional tests or services during the same visit that aren't covered under these preventative benefits, you may have tp pay coinsurance, and the Part B deductible may apply." What is there in either a CMT G0438 or G0439 exam that is not covered in a CMT 99397 exam; and, why wouldn't I just be billed for whatever a CMT 99397 exam covers that is above and beyond the scope of a G0438 or G0439 exam? Am I being defrauded by my medical service provider, or am I just dealing with a coding department that is merely ignorant?

Mark, great question. I started to reply here in this comment thread but soon realized I needed more space to write so I put in into a post. Click on this link: https://www.capturebilling.com/am-i-just-dealing-with-coding-department-that-is-ignorant/ . This will take you to the post where I attempt to answer your question. If I did not hit the mark please leave follow up questions and your comments on that post. Thanks again for your question. –Manny

(con't from previous comment) When I asked them why they didn't bill Medicare for a Wellness Exam, which I subsequently learned they would have billed under CMT G0439, I was informed that because I had received a CMT 99397 physical they couldn't bill Medicare for a Wellness Exam and then bill Tricare4Life and me for the additional services over and above the Welness Exam, as that would be considered fraudulent. I then asked what Medicare would have billed for the Wellness Exam and was told $254.00.

In November 2011 I scheduled a Wellness Exam after receiving a notice from Medicare. I turned 65 on November 16, 2010, so this was my initial notice. My physician explained the limited scope of the exam and recommended that I get a full physical, which I agreed to. Last month I received a bill for approximately half, $116.87, of the total $228.00; Tricare4Life picked up the balance of $111.13. I called the billing office and asked them why Medicare had not been billed for any part of the exam. I was informed that Medicare will not pay any part of the CMT 99397 physical.

The word "wellness" throws us because most of our pts have a health issues. That's why they come to the Dr. to get help managing their illnesses. The preventative exam doesn't fit either: if they'd practiced preventative measures long ago, they probably wouldn't have diabetes, htn, hi-cholesterol, etc. Yet bill 99215 to Medicare for annual review of all their issues and make medication adjustments and do lab reviews, and EKG, etc, and the pt calls when they get the statement after Medicare's paid and they want their visit "rebilled with the wellness code — it's free. Medicare said so." Most of the elements for the G4038/G4039 are covered in the 99215 but there was so much that was medically necessary. It's hard to find a code that everyone's happy with, from pt to Dr. to biller!

Can a Medicare wellness visit be billed out of POS home, assisted living facility or nursing home?

Laura, based on the guidelines provided by CMS in MLN Matters, MM7079, there are specific billing guidelines to billing for a specific place of service (POS) but there looks like there is no exclusion as to where the Annual Wellness Visit may be performed. More information can be found under the CMS Manual System. These resources should be able to help you out and answer your question fully. –Manny

I am having problems with the medicare hmo’s more than anything. This is what I am billing the HMO–g0439 dx v70.0, g0403 dx v17.3, g0328qw dx v76.41, g0101 59 dx v72.31. I am getting a denial stating the procedure code is inconsistent with the modifier used or a required modifier is missing and the benefit for this service is included in the payment/allowance for another service/procedure. Help!!! We typically bill our preventative medicine visits as g0438 or g0439 and g0403, g0328 and if applicable g0101 59. Any suggestions?

Jenny, to try to help better answer your question, I will respond to each individually billed charge you mentioned:

G0439 / V70.0 This billing seems appropriate. If this particular line item is denied then I would suggest double checking the frequency and date of coverage of the patient (for example, should this have been billed as a G0438 initial AWV instead, or as a G0402 IPPE?). Otherwise we frequently bill this out just as you have listed and receive reimbursement.

G0403 / V17.3 The only appropriate time to bill out the EKG as a G0403 is in conjunction with the G0402 IPPE “Welcome to Medicare” exam. It is a once in a lifetime benefit. If a patient is seen for the AWV and the provider also performs an EKG we will bill out the EKG as a 93000 with a diagnosis that indicates the medical necessity of the EKG. For one of our Medicare Carrier’s there is a list of diagnosis codes that supports medical necessity. Please check your carrier’s website to find a list of appropriate diagnoses. Dx code V17.3 is not on this list.

G0328-QW / V76.41 There are specific rules, please check CMS or your MAC website. Is CPT code 82270 (Stool Occult Blood) a more appropriate code for you to use? You may want to look into it. Also, look at V76.51 (Screening for Colon Cancer). Please see the following link for additional information and note that CMS also indicates to contact the local Medicare Contractor for guidance for both the G0328 and the 82270.

G0101-59 dx v72.31. The Medicare Pelvic and Breast Exam G0101 has very specific billing guidelines. Although this code as listed on the quick reference chart can be billed with the V72.31, we’ve found that our Medicare Carrier does not accept this dx and requires any of the other diagnoses instead (V76.2, V76.47, V76.49). Please be sure to check with your local carrier.

***As always with billing Medicare for preventive services be sure to have the proper ABN completed, signed and dated.

You can see why there is a trend for doctors to have Certified Professional Coders on staff and why practices are outsourcing their medical billing. Medicare is making it more complicated every day for medical practices. –Manny

What is the appropriate billing for care plans and the recerts. We are having trouble getting Medicare to pay anything on these. Can someone give me advice on what icd9 and cpt codes you are using?

We do have clients that we do billing for and have the following pointers for you:

Appropriate billing codes for Home Health Certificates: G0180 *Dx codes are used in order that is on the Home Health Certificate *Also the home health agency # that is on the right-hand side of the certificate, must go in box 23 of your claim form, if not it will reject. *The DOS must be the date that is the start date on the Homehealth Cert.

Home Health Recerts (G0179) do not pay with our local carrier so we do not bill for them.

Example: The home health certification days are 12/29/2012-02/26/2013. The Doctor fills out another one on 02/27/2013. You would bill another G0180 for DOS 02/27/2013. You may only bill and be paid for 1 certification during the certification dates. Even if the patient switches agencies, Medicare only allows payment every 60 days.

If there is an addendum or change of care plan, it is inclusive and you may not bill for it, hence why we do not bill G0179.

We found the following information on our local Medicare carrier (Novitas) which has some great information about billing and the requirements for Care Plan and Certifications/Recerts.

See Physician Care Plan Oversight Services and Physician Certification and Recertification of Home Health Services on the Novitas website. Make sure to check with your local Medicare carrier for specific rules in your jurisdiction.

I'm having the same issue as Christine. We are billing G0438 and 99214 with 25 modifier and getting them all denied. We billed with V70.0 as the primary dx code. Medicare is no help at all on clarification. Do I have to have v70.0 secondary?

We have not had this denied as long as everything is billed properly with appropriate modifiers and diagnoses. We frequently bill out either the G0438/G0439 V70.0 with an office visit with modifier 25 for additional distinct problems. We are reimbursed by Medicare for both the AWV and an office visit if billed out properly.

However, we have come across the following problems:

Billing out either the AWV or IPPE and getting a denial for not using the appropriate CPT code. For example we billed out a G0438 but it should have been a G0439, patient was seen and billed for the G0438 by another provider. We corrected the claim and received payment. Also we had billed out a G0438 but should have billed out the G0402 instead, corrected and got this reimbursed by Medicare. Note that we billed these all with the V70.0.

Also frequency/date of service could be an issue – have you double checked the dates of service between the G0438 and G0439, or between the G0402 and the G0438?

What is the exact denial code that you are getting on the EOBs?

We have found the carrier websites to be very helpful. In our area we bill out to both Trailblazer and Novitas. Have you had any luck contacting your local carrier provider representative?

Also see the CMS website and Guide to Medicare Preventive Services.

Manny, I am having a similar problem where I billed out an AWV and a 99204. Medicare paid the 99204 but said the G0438 was mutually exclusive. Any thoughts?

This is how I billed it: V70.0 – G0438 715.96, 780.52, 401.9 – 99204-25

Thanks, Valerie

Valerie, there has got to be more to this Annual Wellness Visit (AWV) denial because the way you have it coded should pay. We have no problem getting paid for claims that are similarly coded.

What was the denial code you received from Medicare? It could be something as simple as frequency (since this is a new patient to your practice they could have had the G0438 with another provider and you need to bill out the G0439 instead) or missing a referring physician, etc.

Let me know what you find. –Manny

It's a United Healthcare Medicare policy. I just called them about it to see if they can explain the denial in more detail and all she could tell me is that the G0438 is mutually exclusive to the 99204-25.

A provider has ordered labs on a patient that will be seen on his 65th birthday for the Initial Medicare Wellness visit. What diagnosis does the provider use for these labs? Medicare will not accept the V70.0 code.

As labs are not considered a part of the IPPE or AWV submitting them with the V70.0 and not showing medical necessity would definitely result in a denial for non covered, routine services. As Medicare has such stringent requirements for billing, the labs can only be billed if medical necessary and appropriate versus any annual code, based on their documentation.

Hi, the dr. that I bill for wants to bill a G0439 with and office visit 99213 using a 25 modifier. I called medicare and they said I can't do this but the doctor insists this will get paid. Have you ever heard of this?

We have never heard of this being denied as long as everything is billed properly with appropriate modifiers and diagnoses. We frequently bill out either the G0438/G0439 with an office visit with modifier 25 for additional distinct problems. We are reimbursed by Medicare for both the AWV and an office visit if billed out properly.

Hey Manny so im setting up a patient for G0438. Can I just bill this with dx V70.0 or do I have to use a cpt code 99385-99387 with that? Also if both need to be used do I have to add a modifier 25?

Yes you can bill G0438 with V70.0. If you are also performing a Routine Preventative Medicine Physical Exam for a Medicare patient (which is different than the Annual Wellness Visit-G0438) you can bill the age appropriate 99387 or 99397 CPT code also with a V70.0 diagnosis. A modifier 25 is not needed. Check with your local Medicare carrier for their specific rules.

Medicare does not recognize the 99387 or 99397 code, G0438 is this Preventive replacement code. You are incorrect Wellness and Preventive are the same.

Tricia you are correct that Medicare does not cover 99387 (new patient) or 99397 (established patient) Routine Preventative Medicine Exams, typically referred to as Annual Physicals. If this non-covered services is performed the Medicare patient can be billed directly and an Advanced Beneficiary Notice (ABN) is not needed. Note that some secondary insurance companies do cover the routine physical.

Many providers believe that the Annual Wellness Visit (AWV, G0438 and G0439) is the same as a Routine Preventative Exam. My guess is they are going by what they may have heard in the media that Medicare covers check-ups. The media has been misinforming doctors and patients. A Routine Preventative Exam and AWV are two different services. The AWV has very specific questions that a providers must ask and properly document in order to be able to bill for the service. Take a close look at the requirements in the CMS MLN Matters Publication MN7079 and then take a look at the requirements for 99387/99389 Routine Physical in your CPT book and you will be able to see that the two services are completely different.

I foresee providers documenting the AWV as a Routine Physical and not documenting what is required by the AWV, getting audited and having to return the money (plus penalties) to Medicare because the documentation does not support the G0438 coding.

If your physicians are performing both a 99387/99397 and a G0438/G0439 they should bill for both and get paid for both. –Manny

Medicare G0438 – G0439: New Annual Wellness Visit Codes is an impressive share. Thank you for this article.

If a patient comes in for lab review would that be considered a well check visit? I dont believe so but some others are saying it is a well check.

If a patient is coming back to review their labs it probably means that there is an abnormal result the physician wants to discuss with the patient. You may have to look at the chart notes to be sure but this is probably the case. It should not be considered a well check.

I would like to ask what Dx would you code to go with G0438/G0439?

Shawn per Medicare you can use V70.0. Go to the CMS website to get more information on AWVs.

How do you bill EKG (cpt and dx) with G0439?

Frank, bill the EKG (93000) with a dx that indicates medical necessity if appropriate. Medicare is very specific about which diagnoses indicate medical necessity for this CPT code and can easily be found on either the CMS.gov website or at your local MAC website. For our area, we bill to Highmark and on their website it is easy to do a search on a specific code and billing instructions. If the EKG is done because it was not medically necessary, according to Medicare, then it will not be reimbursed and the EKG will have to be written off. Hope this helps.

Routine EKGs are not covered. The only exception is the Welcome to Medicare EKG. There is additional information on our website about Welcome to Medicare billing: https://www.capturebilling.com/welcome-to-medicare-visit-ippe/

Last year we were billing G0438 and G0403 (EKG) with dx V70.0 and both were paid. This year, we billed, on the same pt, using G0439 (dx V70.0) and 93000 (other dx) and the 93000 was denied. How do we bill EKG with a G0439?

Medicare patient biled 99214 w 401.9 ,250.00,585.1,v58.69 also had 93000 for 401.9 . having a problem w meddicare paying ekg but if I add 59 modifier it will pay . Is this correct?

Medicare will only allow an EKG for diagnoses that indicate the medical necessity of the EKG. Medicare is very specific about which diagnoses indicate medical necessity and for our MAC, Highmark does not allow for the 401.9. Please check either the CMS.gov website or your local carrier’s website for specific billing information and medical necessity for the EKG. For example, based on the diagnoses you’ve provided the only applicable diagnosis is probably going to be the V58.69.

HI Manny could you please tell me if there are any cpt codes to bill medicare for tetnus shot or dtap? I can not get those to get paid by medicare if i bill under cpt code admin 90471.

Thanks Mirna

These vaccines are not covered by Medicare although secondary insurance may pay. If secondary does not pay we bill the patient. An ABN is not needed but you may want to use a voluntary ABN just to let your patients know they may be responsible for payment.

Regarding the PT AWV: we are looking for clarification on a point. Can a MC patient see more than one provider in a years time for the AWV? that is to say can he see an MD for one AWV and the next week see a PT for a review of functional ability and be cover by both visits?

I work in the Rehab dept of a small rural hospital. We have a few questions regarding the Annual Wellness Visits (Initial and subsequent). A Physical Therapist/Occupational Therapist is medical professional and a licensed practitioner, so it would appear that we may perform the annual visits for our rural population. 1)Do we need an MD reperral for this as we otherwise do? 2)What is the typical re-embursement for these visit? 3)Will Medicare cover for an MD visit as well as a PT visit to one individual within the same time frame?

After reading the definition of a medical professional it does look like a Physical/Occupational Therapist would qualify. I have not come across that. In addition there are special rules for rural hospitals that may apply. At any rate you can rest assured that the claim will deny if if they are not considered an Eligible Provider. Yes, as with other Medicare claims you should have a referring provider.

The reimbursement for the AWV depends where you are located but the national average is 166.44 for G0438 and $ 110.96 for G0439.

The Annual Wellness Visit should be paid independent of any other service provided on the same day. Hope this helps and gets you pointed in the right direction.

Thank you for getting back to me. I am curious about the special rules for our being a rural hospital. Can you tell me about that?

We don\’t deal with rural areas much but in my reading I have heard that the government does have some special programs in these areas that may be undeserved. You may want to talk to your Medicare carrier rep to see what information they have.

I am interested in knowing if you received Medicare reimbursement when billing an AWV under a therapist? Would you also be able to bill an eval on the same day?

I have been trying to get a correct Medicare code for a direct face to face homcare patient code. I have been billing 99366 to Medicare and they are denying it with a denial code stating “This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service /procedure has not been recived/adjudicated.” I have read and read and haven’t come across what I am looking for please help me. Thank you; Erika

Erika, upon researching this CPT code there are specific guidelines that must be met and we just want to make sure the following criteria is met:

99366 Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified health care professional

***Are you billing for a nonphysician?

Face-to-face participation by minimum of three qualified people from different specialties or disciplines

***Is there a minimum of 3 qualified people from different specialities? If so, who is billing for each provider? Are you billing for all three providers? Have you coordinated billing with the other providers if applicable?

Only participants who have performed face-to-face evaluations or direct treatment to the patient within the previous 60 days

There are several CPT codes for home visits. Do any codes from 99341 – 99350 or 99500 – 99602 apply?

I don\’t have enought information to give you a good reason why you are getting those denial codes but hopefully the questions I raised can point you in the right direction.

Medicare's new guideline is requiring a face to face visit with the homecare patient to justify their actual needs in having home care agencies to come to their house daily/weekly/or whatever they are assigned. Our doctor is just the patient's primary care physician that signs off on the patients care plan, home care orders, reviews and changes pt's medication/treatments per home care agencies request. We talk to the patient/caregiver/agencies if our doctor has 30 min. of documentation per month then we can bill G0180,G0179, G0181.

What we need is a code to bill when the home care agency requires an in office face to face with the homecare patient to agree on the need for home care and the services they are going to provide. The patient is seen in office by the physician.

I dont believe 99341-99350-99602 apply because that in performed in the patient's home and we perform the face to face in office.

I have been erroneously billing G0439 last year (2011) for the AWVs and Medicare paid. Now it’s time for the same patients to come back in for another AWV and I have been billing the same G0439, but Medicare is now denying it. Do you think Medicare is denying this year’s G0439 because I should have been billing G0438 for all those first-time AWVs? What should I do. I am kind of thinking I may have to refund Medicare all of the payments for the G0439 last year (2011-because I should have been billing G0438 instead) and then rebill with the G0438 for all those patients in 2011. What do you think?

Most likely Medicare is denying the G0439 because the G0438 should have been billed in 2011. As these codes were only effective beginning 1/1/11 the appropriate CPT code to bill for the AWV is the G0438 and the subsequent G0439 in the following year. Also make sure that you are checking for frequency, if the initial AWV was billed out less than 12 months ago then that might also explain the denial. In our experience, it would be appropriate to rebill the visits as the G0438 if appropriate and then contact Medicare with the error and ask them if they will initiate retraction based on the corrected claim or if they want a refund issued to them. Some of the MACs are great about direct contact. We have been able to call Highmark Medicare in our area and deal with redeterminations using their dedicated redetermination phone number. We also correct claims via the redetermination center. Their representatives are great about advising us as to how they want specific things handled. Giveyour local Medicare Carrier a call.

I have a provider that is doing some of the wellness checks and she is aksing me if this fees could be applied to the deductible for the patient or it this is something that does not get applied to the patient deductible?

That solely depends on the patient’s individual insurance policy. In our experience we have seen deductibles on both wellness and sick visits and it depends directly on how the insurance company processes each individual’s claim. A way to address this is to check the patient’s eligibility on the insurance websites. The websites are usually a great guideline and may give you additional information, especially on deductible percentages and whether or not wellness visits require a copay – however, we never really know until the claim is actually accepted, processed and paid by the insurance company!

When is 99397 used vs G0438? Which would be the best way to be paid since some folks balk at 99397.

With Medicare it’s never how to code to get paid it is what procedure was performed and was it medically necessary. Then you work on getting the claim paid properly which may mean getting payment from the patient. That said, 99397, Routine Preventative Visit is completely different than a G0438, Annual Wellness Visit (AWV). You can actually bill for both codes at the same visit if you performed both services and documented properly. The post above outlines what is part of the Annual Wellness Visit. Your CPT book should list what must performed and documented for a 99397 which is a non-covered service. The practices we service bill for both visits and the patient pays for the 99397. There are also times when there is a Well Woman Exam given at the same time and we that we carve out of the 99397 and bill Medicare a G0101 and Q0091.

Good posting. Thank you all. I have a question about the G0439. I added a Modifier 25 to it and added the 93000 with a ICD for 401.9. I got a rejection from Medicare saying the Modifier is not right. Can I add Modifier 59 and resubmit. Also, if the Doc did a male exam can I add G0101 to it. Need help.Thank you.

Keke, I have a few questions for you before we can point you in the right direction. First of all, a modifier 25 should not be necessary and is usually not billed out on the G0439. In fact, depending on what was billed, a modifier should not be used. What are the exact services that you billed out for and what are the diagnoses?

The issue with the EKG may be the diagnosis. Our local Medicare carrier has a list of diagnoses that indicate the medical necessity and usually HTN is not billable. Check with your local carrier.

The G0101 is for the female Pelvic and Breast Exam. Was the exam done for the Digital Rectal Exam? Let us know exactly what you billed and maybe we can help you!!

Kinda confused on the "what is included in an AWV w/PPPS?" from MLN matters, pg2-3. Does all 11 of these have to been be done at the visit. And is it true this these codes (G0438,G0439&G0402) can be used at any speciality Dr. Also,can you bill a G0438/G0439 w/a pap and pelvic.

Yes what is listed in MLN Matters is what you must do and document in order to bill a Annual Wellness Visit (AWV). The only practices we have using G0402, G0438, and G0439 are primary care practice. You can bill the AWV with a pap and pelvic. You can also bill a routine physical 99387 or 99397 if it is done. So technically you can bill the following:

99387 Routine Preventative Medicine Exam G0438 Annual Wellness Vist G0101 Pelvic and Breast Exam Q0091 Pap

If a patient had a service with 99385 and after 4 years he again come for preventive visit, shall we bill 99385 or do we consider it as periodic visit and bill 99396. (Since if the patient have no service between 3 years we consider it the patient again as new patient)

Thanks Samson

Samson if a patient has not been seen in your office for any reason for over 3 years then that patient would be considered a new patient and it would be appropriate to bill a new patient CPT code. Also keep in mind that with the preventative medicine codes you not only have to choose new or existing patient but you must also consider the patients age when choosing the appropriate code. Let me know if this helps.

99385 – New Patient Preventative Medicine Visit (Age 18-39 years) 99396 – Established Patient Preventative Medicine Visit (Age 40-64 years)

I would like to know the right way to bill balance test to medicare, the are bunduling the cpt codes 92270 and BCBS, when I call Medicare they said go to cci, but I can not find anything, can you help me with that?

Hi all can I bill G0402 medicare with v70.0 and with 99204 ?

Yes you can bill G0402 with a V70.0. As for billing a 99204, per CMS "Medicare payment can be made for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201-99215) billed at the same visit as the IPPE when billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member." Make sure there is an appropriate problem oriented, medically necessary diagnosis for your 99204.

Hi Manny. I found it helpful on the CPT book that also states "If an abnormality is encountered or preexisting problem is addressed IN the process of performing this preventive medicine evaluation and management service, and IF the problem or abnormality is significant enough to require additional work to perform the key components of a problemm-oriented E/M service, then the approriate Office/Outpatient code 99201-99215 should ALSO be reported. Would you first code the E/M w/mod 25, then the G-code or the reverse? Thanks

Manny I was curious as well to whether use the 25 modifier on the line with 99214 or the G0438 when these 2 services are performed in the same day, Or does it even matter?

Some really fantastic posts on this website, thanks for contributions.

I want to say thanks for taking the time to explain the Welcome to Medicare exam to me. You guys took time out of your busy schedule and helped me to understand it . Thanks again.

Let's face it , G0438 involves only vital signs, weight, and height, and then talking to the patient; it is all about risk, and not about illness or hands on physical exam. I have been adding it on to a non physical exam/routine follow up visit., when we sit and talk about what Medicare thinks we need to discuss. What is your feedback?

We have come across physicians that were doing a full physical exam becasue that is what they thought an AWV was.

We have been trying to get the EKG paid with the g0438 it was a medically necessary icd code and still it was denied we also tried with the 59 modifier not sure what else to do I contacted medicare they referred me to their web site I am from a PCP office anyone know how else to get the ekg pd

They don't pay with mod 25 for 93000 when billed with g0438. So I tried 59 mod. and it did work . they paid approx $14 and made $5 as coins. Maybe you should send it for reconsideration.

I have a question. I heard that these wellness codes G0438-G0439 can only be billed three years after they become new to medicare or after you bill the first one welcome to medicare? Is this true or can you bill every year? Thanks

When a Medicare patient first enrolls into Medicare, during their first year they can have a “Welcome to Medicare” exam, G0402. This exam must be done within 12 months of enrolling. The next year the patient can have an Annual Wellness Visit (AWV), G0438 first AWV. In the following years you will bill G0439 annually for the Subsequent Annual Wellness Visit.

Now if a patient has already had their “Welcome to Medicare” exam or if they are no longer eligible because it is beyond 12 months of enrolling into Medicare, then you can use the AWV G0438 for their first visit.

Please note there are different requirements for each visit type and that the Annual Wellness Visit is NOT a Routine Complete Physical Exam. It may still be appropriate to bill a 99387 or 99397 if that service is performed. The patient will be responsible for the fees as Medicare does not cover most routine preventive care.

Hopefully this answeres your question. If not shoot me back another comment.

Hi Manny can I bill 99387 or 99397 to medicare with v70.0 to medicare and with G0438 will i use v70.0 dx? Another question I have do you know if there such thing a mini mental status exam cpt code? I work for geriatric doctor so we have lots of thos patients. Thanks Mirna

Yes you can bill both with V70.0. Remember that these are two different exams. If you are performing the services on the same day make sure they are documented properly and separately. I have heard that some practices will bring patients back on another day to do the 99387. I have not heard of a mini status exam CPT code. That may be something that could be a separate visit if there are some significant issues.

Manny, I've been reading my code books trying to figure out what constitutes an "Annual Routine Preventative/physical exam" (99311-99397) and AWV…. I'm having a hard time determining when to use the Gcodes and when to use the preventative visit codes. I've read your VERY helpful blogs about it but am completely confused when it boils down to the difference of the two. thanks a million!

I attended an annual HOMNY meeting in which the G0438 and G0439 codes were discussed. I work at an Oncology & Hematology practice , and it was not stated by Mr. Bovoso from Medicare that it only pertain to Primary Care billing for these services. I did a test on a patient who had Multiple Myeloma already established and Medicare paid us for this procedure.

Please shed some light since the information that was given was not appropriately addressed by the above mentioned.

I just called mEDICARE REGARDING THE SAME PROBLEM. i WAS TOLD THE 93000 WAS BUNDLED WITH G0438. i I ASKED DOES THIS NEED A MODIFIER AND SHE SAID YES. i THEN ASKED WHICH CODE REQUIES IT AND WAS THEN TOLD TO LOOK AT THE ANSI TABLE COLUM 2. i STILL CAN NOT FIND. HELP.

The only time an EKG is covered by Medicare is with the IPPE. Bill out the EKG with the appropriate G code (G0403, G0404, G0405) – when it is a screening EKG as a result of a referral from an IPPE.

93000 can be billed out with the AWV G0438/G0439 but needs to have a dx that indicates medical necessity as an EKG with a diagnosis of V70.0 that may have been sent in conjunction with the G0438 will not get paid – Medicare doesn’t cover preventive services meaning EKG with dx V70.0. It will definitely deny as inclusive.

The only reference I’ve found on the CMS website is here on page 24 about half way down the page: http://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf

“Should an additional medically necessary EKG in the 93000 series need to be performed on the same day as the IPPE, report the appropriate EKG CPT code(s) with modifier – 59. This will indicate that the additional EKG is a distinct procedural service.”

Good luck with the ANSI Table Column 2.

Modifier 25 is used to un bundle the 93000 (ekg?) also you need a referring Dr. on HCFA form I for get what box it is but medicare will not cover unless you a referring Dr. Even if you do them in the same office and it is the same Dr. You still have to but the billing Dr.'s name in the referring Dr. spot to have it covered.

USE A 25 MODIFIER ON THE OFFICE VISIT LINE. IT WORKS EVERY TIME.

I am in an Urgent Care and recently had a G0438 denied due to POS, I asked Medicare and the rep said it is allowed but you must use a modifier, I have looked and I am not sure which modifier to use,

We are having the same problem but it is not due to the dx code. The comment at the bottom of the eob states that " this service/procedure requires that a qualifying service/procedure be received and covered.

What does that mean? Up until now 93000 was being covered with the g0438 and our doctor sometimes is able to bill a regular office visit along with the g0438 due to the extensive visit/medical problems a patient has.

When I try to call Medicare they are unwilling to help me, they just say look at the website. Thank you in advance for your help with this.

Tina can you give us a bit more info? What were all the CPT and ICD-9 codes you billed with this visit? Who is your local Medicare carrier? Your denial code is very strange. Hopefully we can point you in the right direction.

In my experience it means that the referring/ordering physician is missing on the claim.

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When billing G0438 or G0439 a wellness visit with a EKG 93000,we billed G0438 and 93000 and placed a medical dx on the 93000 yet was still denied for the EKG does the EKG need a modifier?

Phyllis a modifier is usually not needed for the 93000 EKG. One of the problems we come across when an EKG is denied by Medicare is that the reason for the test, or diagnosis, is not considered medically necessary. Check the Local Coverage Determinations (LCDs) of the Medicare carrier in your area. They should have a list of ICD-9 codes they deem medically necessary. If the diagnosis is not on that list then it is considered not medically necessary and the EKG will not pay. Make sure you have a valid ABN on file in those cases to be able to bill the patient.

Manny, I am unable to find what is considered an interpretation of an ECG. Is “normal sinus rhythm” enough to be an interpretation? If no, then how many items need I document (rhythm, QRS, intervals, ST segments, etc) to be considered an interpretation.

Here is some some information from Medicare CAC, June 1995. Its talking about the Emergency Department but I should not make a difference in regard to documentation.

EKGs • Document the interpretation of the tracing in a separate section of the ED chart. • For EKGs, the interpretation must include appropriate comments on any 3 of the following 6 elements: (1) the rhythm or rate (2) axis, (3)intervals, (4) segments, (5) notation of a comparison with a prior EKG if one was available to the ED physician, and (6) summary of clinical condition. “An EKG with interpretation must have the full graphic tracings with formal written or printed interpretation on file for review. The interpretation should appear on the designated sections of a page formatted EKG or written in the clinical records. Interpretations should include appropriate comments on rhythm, axis intervals, acute or chronic changes and a comparison with the most recent tracing. While every single parameter is not required for each tracing, the appropriate measurements must be mentioned if the purpose of repeated EKGs is to monitor the effects of a given parameter, e.g., the QT interval. For example: – EKG reveals normal sinus rhythm, no axis deviation, no acute changes. – EKG reveals normal axis and intervals, no previous EKG for comparison. – EKG reveals atrial fibrillation, rapid ventricular response, non-specific ST-T wave changes – EKG reveals normal sinus rhythm, normal axis, T-wave inversion in V3 and V4 and T-wave flattening and high laterally. No EKG was available for comparison. – EKG reveals normal sinus rhythm with rate of 66, PR and QRS intervals within normal limits, some QRS complexes in lead III and T-wave abnormalities in I and aVL, but when compared to prior EKG there is no acute change noted. RHYTHM STRIPS Rhythm strip interpretations cannot be billed when they are done at the same time as a full EKG. However, they can be billed when performed at a time different than the EKG and when the medical necessity of the rhythm strip is clear. When clearly necessary, each may be billed separately. Documented change in a patient’s condition or response to medication would allow separate reporting of a rhythm strip after an EKG was done.

needs modifier 59

Can I use 25 modifier for G0438 if there is 82274 in the case Medicare Preventive services? Patient have additional dx of E78.5 other than z00.00

Typically when billing any additional services we always analyze which modifiers would be appropriate to append to ensure payment. However, in this scenario the -25 would initially not be used because the 82274 is not considered a “procedure”, it is a lab test.

http://www.wpsmedicare.com/j5macpartb/resources/modifiers/modifier-25.shtml

Have you already submitted the claim without the -25 and was it denied?

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We have started billing 99497/33 along with our G0438/G0439 visits. 99497 has been paid, however, whenever there is a Q0091 added and paid, they are bundling the 99497 and not paying it. Medicare says wrong modifier, but if we take away the 33 then it will go toward patient responsibility. Any suggestions???

Hi Aimee —

It looks like there is a CCI edit. Q0091 conflicts with 99497. Check it out on your Medicare carriers website.

Excellent reference, thanks.

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CPT CODE 99391, 99395, 99396, 99397, 99394 – Preventive Exam

Sep 12, 2016 | Medical billing basics

CPT CODE AND Description

99391 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) – Average fee amount $90

99392 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years) Average fee amount $105 99393 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) Average fee amount $110

99394 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Average fee amount $120

99395 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years 99396 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years 99397 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older

Referral/notification/preauthorization requirements

There are no referral/preauthorization requirements for well baby/well child care visits when provided by a contracted FCHP primary care physician within the member’s product network.

Billing/coding guidelines

For new patients making a well baby/well child care visit:

• For infants under age 1, use CPT code 99381.

• For children ages 1 to 4 (early childhood), use CPT code 99382.

• For children ages 5 to 11 (late childhood), use CPT code 99383.

• For children ages 12 to 17 (adolescent), use CPT code 99384.

• For children age 18 (adolescent), use CPT code 99385.

For established patients making a well baby/well child care visits:

• For infants under age 1, use CPT code 99391.

• For children ages 1 to 4 (early childhood), use CPT code 99392.

• For children ages 5 to 11 (late childhood), use CPT code 99393.

• For children ages 12 to 17 (adolescent), use CPT code 99394.

• For children age 18 (adolescent), use CPT code 99395.

Preventive Medicine Visits • Not all insurers pay for preventive medicine visits. For example, these visits are not covered by Medicare.

If you suspect a patient does not have coverage, advise him or her of your billing policies.

• Insurers that do cover preventive medicine visits (eg, many HMOs) generally reimburse them at relatively high rates.

• Regardless of whether a preventive medicine visit is covered, the relevant codes can be used alone or in conjunction with a code for an E&M service (see below).

CPT 99391 - Preventiv Exam - Less than 1 year

Patient and Visit Preventive Medicine Code

New patient, initial visit Age 40 through 64 years 99386 Age 65 years and older 99387 Established patient, periodic visit Age 40 through 64 years 99396 Age 65 years and older 99397

Preventive Medicine Services: Established Patients

Periodic comprehensive preventive medicine reevaluation and management of an individual includes an age- and gender-appropriate history; physical examination; counseling, anticipatory guidance, or risk factor reduction interventions; and the ordering of laboratory or diagnostic procedures. CPT Codes ICD-9-CM Codes

99391 Infant (younger than 1 year) V20.31 Health supervision for newborn under 8 days old

V20.32 Health supervision for newborns 8 to 28 days old

V20.2 Routine infant or child health check

99392 Early childhood (age 1–4 years) V20.2 Routine infant or child health check

99393 Late childhood (age 5–11 years) V20.2 Routine infant or child health check

99394 Adolescent (age 12–17 years) V20.2 Routine infant or child health check

99395 18 years or older V70.0 Routine general medical examination at a health care facility

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402 are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a pre existing problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse the Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.existing problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse the Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

Policy Statement

Preventive medicine services are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from diseaserelated diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the preventive visit, and significant elements of related E/M services are provided during the same visit. When this occurs, Medica will reimburse the preventive medicine E/M service at the contracted rate and the problem-oriented E/M service at 75% of the contracted rate, when appended with modifier 25.

Procedure codes used to bill preventive medicine services are:

** Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397

During a visit for a preventive medicine service, other services may be provided.

HealthWatch EPSDT codes PLUS Evaluation & Management (E&M) Codes PLUS Modifier 25*

PLUS ICD-9 Diagnosis Codes 99381–99385or 99391–99395

The components of the EPSDT visit must be provided and documented.

99203–99215 The presenting problem must be of moderate to high severity Documentation must support the use of a modifier 25

V20.2 must be the primary diagnosis code for the preventive visit Add multiple diagnosis codes for the presenting problem focused evaluation.

THE PREVENTIVE SERVICE E/M VISIT WITH A PROBLEM-ORIENTED SERVICE: AN EXAMPLE

A 52-year-old established patient presents for an annual exam. When you ask about his current complaints, he mentions that he has had mild chest pain and a productive cough over the past week and that the pain is worse on deep inspiration. You take additional history related to his symptoms, perform a detailed respiratory and CV exam, and order an electrocardiogram and chest X-ray. You make a diagnosis of acute bronchitis with chest pain and prescribe medication and bed rest along with instructions to stop smoking. You document both the problem-oriented and the preventive components of the encounter in detail. You should submit 99396, “Periodic comprehensive preventive medicine…, established patient; 40-64 years” and ICD-9 code V70.0, “Routine general medical examination at a health care facility”; and the problem-oriented code that describes the additional work associated with the evaluation of the respiratory complaints with modifier -25 attached, ICD-9 codes 466.0, “Acute bronchitis” and 786.50, “Chest pain” and the appropriate codes for the electrocardiogram and chest X-ray.

Bill Diagnosis code(s) V70.0

Routine exam Procedure code(s) 99396

Preventive service 466.0 786.50

Acute bronchitis Chest pain 99213-25*

Office outpatient E/M service for established patient 93000

Electrocardiogram 71020

Chest X-ray, PA and lateral

*The level of service represents only an example. The level reported should be determined by the documented history, exam and/or medical decision-making.

CPT Code for Initial Evaluation of New Patient (Bold)

CPT Code for Periodic Reevaluation

99381 – 99391 – Under 1 year

99382 – 99392 – 1-4

99383 – 99393 – 5-11

99384 – 99394 – 12-17

99385 – 99395 – 18-39

99386 – 99396 – 40-64

99387 – 99397 – 65 and over

Code 99420 is specific to administration and interpretation of health risk assessment instruments.

Payers may or may not allow use of this code for behavior-related questionnaires such as the Pediatric Symptom Checklist or one of the longer alcohol- or depression-related questionnaires.

Finally, the last of the preventive medicine codes is 99429, Unlisted Preventive Medicine Service. Practitioners are urged to check with the managed care plan or insurance carrier before using this code.

PREVENTIVE CODES THAT SHOULD GENERALLY BE COVERED AT NO OUT OF POCKET COST FOR BCBSIL HMO MEMBERS Preventive Medicine Services – Adult Established Patient: 99394 – adolescent (12-17) 99395 – 18-39 years 99396 – 40-64 years 99397 – 65 years and older Preventive Medicine Services – Pediatric Established patient: 99391 – age younger than 1 year 99392 – age 1-4 years 99393 – age 5-11 years

99211 99212 99213 99214 99215 Mutually Exclusive 99391 99392 99393 99394 99395 99396 99397

Therefore, 99211-99215 is submitted with 99391-99397–only 99391-99397 reimburses.

Preventive Medicine Evaluation & Management (E&M) Services

* Preventive Medicine E&M services should be reported using the age appropriate code from the Preventive Medicine Services section of the most current CPT manual.

* Services rendered should be reported using 99381-99387 for new patients or 99391-99397 for established patients. These codes include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination.

* If an abnormality/ies is encountered, or a preexisting problem is addressed in the process of performing a preventive medicine E&M service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E&M service, then the appropriate office/Outpatient code 99201-99215 should also be reported.

Modifier-25 should be added to the Office/Outpatient code to indicate that a significant; separately identifiable E&M service was provided by the same physician on the same day as the preventive medicine service. Note: An insignificant or trivial problem or abnormality that is encountered in the process of performing the preventive medicine E&M service and which does not require additional work and the performance of the key components of a problem-oriented E&M service should not be reported.

Evaluation and management services including new or established patient office or other outpatient services (99201-99215), emergency department services (99281-99285), nursing facility services (99304-99318), domiciliary, rest home, or custodial care services (99324-99337), home services (99341-99350), and preventive medicine services (99381-99397) on the same date related to the admission to “observation status” should not be reported separately.” (AMA7)

“An E&M service is separately reportable on the same date of service as a procedure with a global period of 000, 010, or 090 under limited circumstances…If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.

REIMBURSEMENT GUIDELINES Preventive Medicine Service and Problem Oriented E/M Service

A Preventive Medicine CPT or HCPCS code and a Problem-Oriented E/M CPT code may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. If the E/M code represents a significant, separately identifiable service and is submitted with modifier 25 appended, Oxford will reimburse the Preventive Medicine code plus 50% of the Problem-Oriented E/M code. Oxford will not reimburse a Problem-Oriented E/M code that does not represent a significant, separately identifiable service and that is not submitted with modifier 25 appended.

Preventive Medicine Service and Other E/M Service

A Preventive Medicine CPT or HCPCS code and Other E/M CPT or HCPCS codes may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. However, Oxford will only reimburse the Preventive Medicine CPT or HCPCS code.

Screening Services

The comprehensive nature of a Preventive Medicine code reflects an age and gender appropriate examination. When a screening code is billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Prolonged Services

Prolonged services codes represent add-on services that are reimbursed when reported in addition to an appropriate primary service. Preventive medicine services are not designated as appropriate primary codes for the Prolonged services codes. When Prolonged service add-on codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Counseling Services

Preventive Medicine Services include counseling. When counseling service codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Medical Nutrition Therapy Services

According to CPT, for Medical Nutrition Therapy assessment and/or intervention performed by a physician, report Evaluation and Management or Preventive Medicine service codes. When Medical Nutrition Therapy codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Visual Function and Visual Acuity Screening

The comprehensive nature of a Preventive Medicine code reflects an age and gender appropriate examination. When Visual Function Screening or Visual Acuity Screening is billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Preventive Medicine Service Provided at the Time of Covered Screening Service

A preventive medicine exam, as described by CPT-4 codes (99384 – 99397), includes a comprehensive age and gender appropriate history, examination, counseling/anticipatory guidance/risk-factor reduction interventions, and the ordering of appropriate immunization(s) and laboratory/diagnostic procedures. Sometimes these other elements are performed during the same visit as the Medicare covered services, particularly G0101 and Q0091. The following pie chart illustrates this circumstance.

The following are examples of screening services that are ineligible for separate reimbursement when reported with preventive medicine services, annual GYN examinations and/or problem oriented E/M services:

• G0101 is included in the reimbursement for:

o problem oriented E/M services (99201-99215)*

o preventive medicine services (99381-99397)

o annual GYN examinations (S0610, S0612, or S0613)

• G0102 is included in the reimbursement for:

• Q0091 is included in the reimbursement for:

o preventive medical services (99381-99397)*

o annual GYN examinations (S0610, S0612, or S0613)*

• S0610, S0612, and/or S0613 is included in the reimbursement for:

Coding for a Problem Focused Visit Within an EPSDT Visit

EPSDT codes

99381–99385 or 99391-99395 The components of the EPSDT visit must be provided and documented

PLUS Evaluation and Management (E&M)codes

99203–99215 The presenting problem must be of moderate to high severity.

PLUS Modifier 25*

Documentation must support the use of modifier 25.

PLUS ICD-9 Diagnosis codes

V20.2 or V70.0 must be the primary diagnosis diagnosis code for the visit. Add the diagnosis codes for the presenting problem focused evaluation.

Effective 4/1/2014 EPSDT/Well Child visits are all-inclusive visits. The payment for the EPSDT is intended to cover all elements outlined in the AHCCCS EPSDT Periodicity Schedule (AMPM Exhibilt 430-1). Refer to AMPM Policy 430 for exceptions to the all-inclusive visit global payment rate. Claims must be submitted on CMS 1500 form. Providers must bill for preventative EPSDT services using the preventative service, office or other outpatient services and preventative medicine CPT codes (99381 – 99385, 99391 – 99395) with an EP modifier. EPSDT visits are paid at a global rate for the services specified in AMPM Policy 430. No additional reimbursement is allowed.

Providers must use an EP modifier to designate all services related to the EPSDT well child check-up, including routine vision and hearing screenings.

Providers must be registered as Vaccines for Children (VFC) Program providers and VFC vaccines must be used. Under the federal VFC program, providers are paid a capped fee for administration of vaccines to recipients 18 years old and younger. For VFC claims incurred prior to 1/1/2013, Providers must bill the appropriate CPT code for the immunization with the “SL” (State supplied vaccine) modifier that identifies the immunization as part of the VFC program.

Providers must not use the immunization administration CPT codes 90471, 90472, 90473, and 90474 when billing under the VFC program. Because the vaccine is made available to providers free of charge, providers must not bill for the vaccine itself.

For VFC services incurred on/after 1/1/2013, Section 1202 of the Patient Protection and Affordable Care Act (ACA) requires AHCCCS to modify how providers submit claims for vaccine administration services.

EPSDT CPT codes well-child visits STAGE (Age) NEW PATIENT CPT CODE ESTABLISHED PATIENT CPT CODE

INFANCY (Prenatal – 9 months) 99381 99391 EARLY CHILDHOOD (12 months – 4 years) 99382 99392 MIDDLE CHILDHOOD (5 years – 10 years) 99383 99393 ADOLESCENCE STAGE 1 (11 years – 17 years) 99384 99394 ADOLESCENCE STAGE 2 (18 years – 21 years) 99385 99395 EPSDT CPT codes for sensory screening SERVICE CPT CODE VISION 99173 HEARING (Audio) 92551 HEARING (Pure tone-air only) 92552 Adult annual preventive care visits

New patient

CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older

Established patient

CPT Code 99395: Periodic Preventive Medicine Established Patient 18-39 years CPT Code 99396: Periodic Preventive Medicine Established Patient 40-64 years CPT Code 99397: Periodic Preventive Medicine Established Patient 65 years & older Adolescent annual preventive care visits

CPT Code 99382: Initial Preventive Medicine New Patient age 1-4 years CPT Code 99383: Initial Preventive Medicine New Patient age 5-11 years CPT Code 99384: Initial Preventive Medicine New Patient age 12-17 years

CPT Code 99392: Periodic Preventive Medicine Established Patient age 1-4 years CPT Code 99393: Periodic Preventive Medicine Established Patient age 5-11 years CPT Code 99394: Periodic Preventive Medicine Established Patient age 12-17 years

Preventive Visit Codes Although preventive visit codes will be accepted (99385; 99386; 99387; 99395; 99396; 99397), Medicare does not establish a rate for these codes. Sage will pay 99385 – 99387 at the rate for code 99203. Codes 99395 – 99397 will be paid at the rate for code 99213.

PARTIAL SCREENING and Modifier usage

Different providers may provide segments of the full medical screen. The purpose of this is to increase the access to care for all children and to allow providers reimbursement for those separate screens. When expanded HCY services are accessed through a partial or interperiodic screen, it is the responsibility of the provider completing the partial screening service to have a referral source to refer the child for the remaining components of a full screening service. An unclothed physical and history screen ( CPT codes 99381 52 EP-99385 52EP and 99391 52 EP -9939552EP) includes the first five sections of the age appropriate screening guide including:

• Interval history; • Unclothed physical exam; • Anticipatory guidance; • Laboratory/Immunizations; and • Age appropriate lead screening. Federal regulations require a mandatory blood lead testing by either capillary or venous method at 12 months and 24 months of age. The provider must use the HCY Lead Risk Assessment form.

PARTIAL SCREENING PROCEDURE CODES – UNCLOTHED PHYSICAL & HISTORY (Established Patient) (Provider must complete Sections 1-5 of the HCY Screening Guide)

Procedure Code (Use Age Appropriate Code) Modifier 1 Modifier 2 Fee

99391* 52 EP $20.00 99392* 52 EP $20.00 99393* 52 EP $20.00 99394* 52 EP $20.00 99395* 52 EP $20.00

*Modifier “UC” must be used if child was referred for further care as a result of the screening. DESCRIPTION OF MODIFIERS USED FOR HCY SCREENINGS

* EP – Service provided as part of MO HealthNet early periodic, screening, diagnosis, and treatment (EPSDT). * 52 – Reduced services. Modifier 52 must be used when all the components for the unclothed physical and history procedure codes (99381-99395) have not been met according to CPT. Also used with procedure code 99429 to identify that the components of a partial HCY vision screen have been met. * 59 – Distinct Service. Modifier 59 must be used to identify the components of an HCY screen when only those components related to developmental and mental health are being screened. * UC – EPSDT Referral for Follow-Up Care. The modifier UC must be used when the child is referred on for further care as a result of the screening.

All Preventive CPT CODE AND description Adult preventive care visits New patient CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older

Established patient CPT Code 99395: Periodic Preventive Medicine Established Patient 18-39 years CPT Code 99396: Periodic Preventive Medicine Established Patient 40-64 years CPT Code 99397: Periodic Preventive Medicine Established Patient 65 years & older

Adult annual preventive care visits New patient CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older

New patient CPT Code 99382: Initial Preventive Medicine New Patient age 1-4 years CPT Code 99383: Initial Preventive Medicine New Patient age 5-11 years CPT Code 99384: Initial Preventive Medicine New Patient age 12-17 years

DIAGNOSIS CODES FOR FULL, PARTIAL OR INTERPERIODIC SCREENS

Providers must use V20.2 as the primary diagnosis on claims for HCY screening services. There are two exceptions. CPT codes 99381EP and 99391EP must be billed with diagnosis code V20.2, V20.31 or V20.32. CPT codes 99385 and 99395 must be billed with diagnosis code V25.01-V25.9, V70.0 or V72.31.

FULL SCREENING PROCEDURE CODES (New Patient) Procedure Code (Use Age Appropriate Code)

Modifier 2 Fee 99381* EP $60.00 99382* EP $60.00 99383* EP $60.00 99384* EP $60.00 99385* EP $60.00

PARTIAL SCREENING

An unclothed physical and history screen (CPT codes 9938152EP-9938552EP and 9939152EP-9939552EP) includes the first five sections of the age appropriate screening guide including:

• Interval history;

• Unclothed physical exam;

• Anticipatory guidance;

• Laboratory/Immunizations; and

• Age appropriate lead screening. Federal regulations require a mandatory blood lead testing by either capillary or venous method at 12 months and

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Initial Preventive Physical Examination (IPPE)

As part of the Affordable Care Act, Medicare provides coverage for an IPPE for patients who have been enrolled in Medicare for less than one year. It is a one-time service, intended to help provide an introduction to insurance coverage, benefits, and give appropriate screening for disease detection and preventive promotion of health. The IPPE must be performed within the first 12 months after the effective date of the beneficiary's Medicare Part B coverage.

An IPPE includes the following seven components:

A review of the beneficiary's medical and social history
Review of the beneficiary's potential risk factors for mood disorders
Review of the beneficiary's functional ability and level of safety
An examination
End-of-life planning
Education, counseling, and referral based on the previous five components
Education, counseling, and referral for other preventive services

Annual Wellness Visit (AWV)

As part of the Affordable Care Act, Medicare provides coverage for an AWV for patients who are enrolled in Medicare. This service may be covered as often as once per year. There are two specific types of AWV: initial and subsequent. Required elements for the initial AWV include:

A self-reported health risk assessment
Establishment of the beneficiary's medical/family history
A health assessment within the office
Establishment of current providers and suppliers of service
Detection of any cognitive impairment that the beneficiary may have
Establishment of a written screening schedule for the beneficiary
Establishment of a list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended for the beneficiary
Furnishing of personalized health advice to the beneficiary, and a referral for further care, if appropriate

The subsequent AWV visit will be updating the patient's past history as established during the initial visit, as well as a new assessment to establish any needed additional treatment. This is a shorter established service. Required elements for subsequent AWVs include:

Update of the self-reported risk assessment
An update of the beneficiary's medical/family history
Update of the list of current providers and suppliers of service
Update of the written screening schedule for the beneficiary
Update of the list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended for the patient
Furnishing of personal health advice to the beneficiary, and a referral for further care, if appropriate

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How to avoid Medicare annual wellness visit denials

If you’re seeing a high number of denials for Medicare annual wellness visits (AWVs), you’re not alone. Identifying whether to code for an Initial Preventive Physical Exam (IPPE, or the “Welcome to Medicare” visit), an initial Medicare AWV, or a subsequent Medicare AWV can be tricky.

Common reasons for denial include the folllowing:

1. Billing a G0438 (initial Medicare AWV) or G0439 (subsequent Medicare AWV) when the patient has been enrolled in Medicare Part B for 12 months or less. This situation instead calls for billing G0402 (IPPE).

2. Billing for a Medicare AWV when the patient only has Medicare Part A . They must have Part B coverage as well.

3. Using the wrong primary diagnosis code. If the primary diagnosis code is problem-oriented (e.g., diabetes or hypertension), Medicare will most likely deny a claim for an AWV, because AWVs are “well visits.” Instead, list a well code (e.g., Z00.0X, “encounter for general adult exam”) as the primary diagnosis.

The IPPE also has a slightly different set of required components (e.g., advance care planning and visual acuity screening with documentation of results in the note) than the two types of AWVs (e.g., instrumental activity of daily living and assessment of cognitive function).

Here are some frequently asked questions to help you further navigate the world of AWV billing, as well as a side-by-side comparison of the three types of Medicare wellness visits.

Q - What is the difference between a Medicare AWV and a preventive visit?

A - Medicare AWVs consist of three specific visit types statutorily covered by Medicare with no co-pay or deductible. They are the IPPE (the “Welcome to Medicare” visit, G0402), the initial AWV (G0438), and the subsequent AWV (G0439). These visits do not require a comprehensive physical exam. Preventive visits (9938X and 9939X) are covered by commercial/managed care and Medicaid plans and require a comprehensive physical exam. They are also include no co-pay or deductible.

Q - Can a Medicare patient receive a preventive visit?

A - Yes, but traditional Medicare does not cover these visits (9938X and 9939X are statutorily prohibited), so patients with that coverage will have to pay 100% out-of-pocket. However, some Medicare Advantage plans cover both Medicare AWVs (G codes) and non-Medicare (commercial) preventive visits (9938X and 9939X). Medicare Advantage patients would need to check their plan benefits to find out if they have coverage for both.

Q - Is the IPPE the same as the initial AWV?

A - No, the IPPE is the Initial Preventive Physical Examination, also known as the "Welcome to Medicare" visit (G0402), while the initial AWV (G0438) is the patient’s first Medicare AWV following the IPPE. These are two different types of visits, and billing a G0438 when the patient was actually only eligible for a G0402 is a common cause of denials.

Q - What diagnosis code should I use to bill a Medicare wellness exam?

A - Use the Z00 family of codes.

Q - Do Medicare wellness visits need to be performed 365 days apart?

A - No. A Medicare wellness visit may be performed in the same calendar month (but different year) as the previous Medicare wellness visit. For example, if a patient had a Medicare AWV on June 30, 2020, then that patient is eligible again on June 1, 2021. If a patient had a Medicare AWV on June 1, 2020, then that patient is also eligible again on June 1, 2021. But if you bill a Medicare AWV for either patient on May 31, 2021, it will be denied, because it is in a different calendar month and too soon.

Q - Can I bill for a Medicare AWV and a commercial insurance preventive visit for the same patient in the same year?

A - Yes, you can do this if the patient has both as part of their covered benefits. Some patients have a commercial payer as their primary insurance and Medicare as their secondary.

Q - Can I perform Medicare wellness visits in skilled nursing facilities or as home visits?

A - Yes. Just make sure the place of service (POS) on the claim corresponds to the correct location.

Q - Can I perform a pap smear or pelvic exam during a Medicare AWV?

A - Yes, and they are both separately billable. Use code Q0091 for the screening pap smear in a Medicare patient. The pelvic exam must be combined with a breast exam and then billed together using G0101. Specific documentation components are required for the G0101.

Q - If a patient has a managed Medicare plan (non-traditional Medicare), can I still bill a G code (G0402, G0438, or G0439) for a wellness visit?

A - Yes. Traditional Medicare and all managed Medicare plans will accept the G codes for AWVs.

Q - Can I bill a routine office visit with a Medicare AWV?

A - When appropriate, a routine office visit (9920X and 9921X) may be billed with a Medicare AWV. Modifier -25 should be appended to the evaluation and management (E/M) code. Cost sharing will apply to the E/M service, though, just as it would without the Medicare AWV. Make sure patients are aware of this, as some may expect that all services provided on the same day as the Medicare AWV are covered at 100%.

Which type of Medicare AWV is this?

— Vinita Magoon, DO, JD, MBA, MPH, CMQ, Baylor Scott & White Health, Temple, Texas

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Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health :

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The COVID-19 public health emergency (PHE) ended at the end of the day on May 11, 2023. View Infectious diseases for a list of waivers and flexibilities that were in place during the PHE.

How do I determine the last date a patient got a preventive service so I know if they’re eligible to get the next service and it won’t deny due to frequency edits?

Learn how to check eligibility . You may access eligibility information through the CMS HIPAA Eligibility Transaction System (HETS) either directly or through your:

Eligibility services vendor
Medicare Administrative Contractor (MAC) provider call center interactive voice response (IVR) unit
MAC provider web portal

Contact your eligibility service vendor or find your MAC’s website .

My patients don’t follow up on routine preventive care. How can I help them remember when they’re due for their next preventive service?

We offer a Preventive Services Checklist so they can track their preventive services.

When can CMS add new Medicare preventive services?

We may add preventive services coverage through the National Coverage Determination (NCD) process if the service is:

Reasonable and necessary for prevention or early detection of illness or disability
U.S. Preventive Services Task Force (USPSTF)-recommended with grade A or B
Appropriate for people entitled to Part A benefits or enrolled under Medicare Part B

We may also add preventive services through statutory and regulatory authority.

The USPSTF Published Recommendations webpage has more preventive services information.

What’s a primary care setting?

We define a primary care setting as a place where clinicians deliver integrated, accessible health care services and are responsible for addressing most patient health care needs, developing a sustained patient partnership, and practicing in the context of family and community. Under this direction, we don’t consider emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices as primary care settings.

CMS Preventive Services
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Annual Wellness Visit | Advance Care Planning | Social Determinants of Health | CPT codes

Annual Wellness Visits: 2024 CPT Codes and Reimbursement Rates

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February 12th, 2024 | 1 min. read

Annual Wellness Visits: 2024 CPT Codes and Reimbursement Rates

ThoroughCare

Content Team

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Annual Wellness Visits (AWV) can be an effective way to embrace value-based care, so it’s important to understand the program's rules and regulations, as well as the different types of AWVs your practice can offer.

In this video, we'll review the 2024 CPT codes and reimbursement rates for AWVs, Advance Care Planning (ACP), and the new Social Determinants of Health (SDoH) assessment including G0402, G0438, G0439, G0468, 99497, 99498, and G0136. We’ll cover the differences between Initial Preventive Physical Examinations (IPPE), Initial Annual Wellness Visits, Subsequent Annual Wellness Visits and when each can be administered.

After watching, you’ll have a better understanding of the elements of an AWV, including health risk assessments, ACP, and the SDoH assessment. You'll also know how to bill for each type of visit if you’re a physician practice, Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC).

Download an Annual Wellness Visit CPT code brochure .

IMAGES

2023 Annual Wellness Visit CPT Codes: G0402, G0438, G0439
What Are the 2022 CPT Codes for Annual Wellness Visits?
What Are the 2022 CPT Codes for Annual Wellness Visits?
CPT Code Guide
Coding for the Annual Wellness Visit and Preventive Services (Transcript)
CPT Codes for Annual Wellness Visits

VIDEO

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2024-03-23 USCTF Continuing Education Course: CPT Code, Therapeutic Taiji, Taiji Safe Landing skills
Medical Billing Training by Salman Gilani
NextGen EHR Operations Advisor
BILLING TIPS ON WELCOME TO MEDICARE VISIT AND ANNUAL WELLNESS VISIT

COMMENTS

2023 Annual Wellness Visit CPT Codes: G0402, G0438, G0439
Reimbursement rates are based on a national average and may vary depending on your location. Check the Physician Fee Schedule for the latest information. Learn 2023 CPT billing codes for annual wellness visits (AWVs) and understand requirements to maximize the value of G0402, G0438, G0439, 99497, and G0468.
MLN6775421
Added information about checking for cognitive impairment during annual wellness visits; ... Report the additional CPT code (99202-99205, 99211-99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient's illness or injury or to improve the functioning of a malformed body part.
2024 CPT Codes for Annual Wellness Visits
Automated CPT code assignment for accurate billing. *Reimbursement rates are based on a national average and may vary depending on your location. Check the Physician Fee Schedule for the latest information. Learn 2024 annual wellness visits (AWVs) CPT billing codes. Understand requirements and maximize the value of G0402, G0438, G0439, 99497 ...
Medicare Preventive Services
Annual Wellness Visit (AWV) HCPCS/CPT Codes. G0438 - Initial visit. G0439 - Subsequent visit. ICD-10 Codes. See the CMS . ICD-10 webpage for individual CRs and coding translations for ICD-10 and . contact your MAC for guidance. Who Is Covered. All Medicare beneficiaries who are both: Not within 12 months after the effective date of their ...
PDF 2020 Annual Wellness Visit (AWV) Coding and Documentation Tips ...
CPCS Code G0439 (Medicare only) - Subsequent Visit. Annual Wellness Visit - includes a personalized prevention plan of service (PPS ) New/Established patient. (effective 03/01/20for the. COVID-19 emergency) CPT Codes 99341 - 99345Home visit for the evaluation and management. New Patient CPT Codes 99347 - 99350Home visit for the evaluation and ...
Annual Wellness Visit Coding Guide
Codes to file claims for an Annual Wellness Visit. Code Type Definition G0438 HCPCS Annual Wellness Visit - initial visit. Includes a personalized prevention plan of service (PPS). ... 1159F CPT II Medications Medication list documented in medical record. *Code with 160F. AWV Coding Guide 8750-9695 R3 (F)
Get Paid with the Annual Wellness Visit
AWV Coding. The two CPT codes used to report AWV services are: G0438 initial visit; G0439 subsequent visit; Requirements and Components for AWV. Requirements and components for G0438 (initial ...
What Are the 2022 CPT Codes for Annual Wellness Visits?
As shown above, CPT code G0468 allows federally qualified health clinics (FQHC) to bill for AWVs. This code covers all three varieties of AWVs at the same reimbursement rate. That said, you would still provide the type of AWV most appropriate based on your patient's eligibility window.
Three steps to coding for Medicare wellness visits
Code for the wellness visit. An initial preventive physical exam (IPPE, or Welcome to Medicare visit) is a one-time physical exam performed within the first 12 months of a patient's Part-B ...
Annual Wellness Visit (AWV) documentation and coding
AWV coding. An ICD-10 Z code is the first diagnosis code to list for wellness exams to ensure that member financial responsibility is $0. The two CPT® codes used to report AWV services are:*. Additional services (lab, X-rays, etc.) ordered during an AWV may be applied toward the patient's. deductible and/or be subject to coinsurance.
Preventive services coding guides
The AMA offers the following coding guidance to improve the billing process for all. Current Procedural Terminology (CPT) modifier 33 can be used when billing for ACA-designated preventive services with a commercial payer. The addition of modifier 33 communicates to a commercial payer that a given service was provided as an ACA preventive service.
How to Bill Medicare's Annual Wellness Visit
Physicians must append modifier -25 (significant, separately identifiable service) to the medically necessary E/M service, e.g. 99213-25, to be paid for both services. For example, for the patient who comes in for his Annual Wellness Visit and complains of tendonitis would be billed as follows: CPT ICD9, G0438 V70.0, 99212-25 726.90 (tendonitis)
Master Annual Wellness Visit CPT Code Guide
Here are some examples of preventive care CPT codes: 99387 - Complete Physical Exam for patients aged 65 and older. 99397 - Complete Physical Exam for patients aged 65 and older (subsequent visit) G0101 - Well Woman Exam. Q0091 - Screening Pap Smear.
CPT Codes for Annual Wellness Visits
G0439: You must use this code for all Annual Wellness Visits following the initial one. Among the AWV codes, this is the last one you will use, and it's the only one you will use repeatedly. There are various factors that define an Annual Wellness Visit. There are even differentiators between the initial AWV and all subsequent AWVs.
Annual Wellness Visits: 2023 CPT Codes and Reimbursement Rates
Annual Wellness Visits (AWV) can be an effective way to embrace value-based care, so it's important to understand the program's rules and regulations, as well as the different types of AWVs your practice can offer. In this video, we'll review the 2023 CPT codes and reimbursement rates for AWVs and Advance Care Planning (ACP), including G0402 ...
Medicare G0438
1. CPT Code: G0439 (All Subsequent Annual Wellness Visits - Covered Annually) - No Modifier Diagnosis Code: Z00.00 (Routine General Exam) 2. CPT Code: 99213 (Established Patient Office Visit) - Modifier 25 Diagnosis Code: E11.9 (Diabetes), I10 (Hypertension), E78.5 (Hyperlipidemia) EXAMPLE POSSIBILITY 2: 1.
CPT CODE 99391, 99395, 99396, 99397, 99394
OVERVIEW. Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402 are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses.
Annual Wellness Visits (AWVs) and Initial Preventive Physical
Procedure Code Tips "Routine examination" CPT codes 99391-99397: Never reimbursed by Medicare; Initial Preventive Physical Examination (IPPE) HCPCS code G0402: One-time service; Within first 12 months of beneficiary's Medicare effective date; 7 required components; Annual Wellness Visit (AWV): initial: HCPCS code G0438: May be covered once; 10 ...
How to avoid Medicare annual wellness visit denials
A - Use the Z00 family of codes. Q - Do Medicare wellness visits need to be performed 365 days apart? ... Yes, CPT 99497 and 99498 can be billed separately as long as minimum time requirements are ...
PDF 2024 Medicare Advantage preventive screening guidelines
to the IPPE, annual routine physical exam or AWV, you may also bill CPT® codes 99202-99215 reported with modifier -25. When medically indicated, this additional E/M service is subject to the applicable copayment for an office visit. ... Only the codes listed on the "wellness visits/routine physicals" chart above are included in the $0 ...
Billing Annual Wellness Visits: Understanding Reimbursement Potential
A subsequent AWV is accounted for by CPT code G0439. The national average reimbursement rate for billing this is $128.03 per month. For ACP, the average rate is $80.56 with CPT code 99497. Assuming you've helped 500 patients complete an AWV in a year, you could expect to generate about $64,015 in reimbursement, annually.
MLN006559
Reasonable and necessary for prevention or early detection of illness or disability. U.S. Preventive Services Task Force (USPSTF)-recommended with grade A or B. Appropriate for people entitled to Part A benefits or enrolled under Medicare Part B. We may also add preventive services through statutory and regulatory authority.
Annual Wellness Visits: 2024 CPT Codes and Reimbursement Rates
In this video, we'll review the 2024 CPT codes and reimbursement rates for AWVs, Advance Care Planning (ACP), and the new Social Determinants of Health (SDoH) assessment including G0402, G0438, G0439, G0468, 99497, 99498, and G0136. We'll cover the differences between Initial Preventive Physical Examinations (IPPE), Initial Annual Wellness ...