Medicare Billing for Well Woman Exam Using Codes G0101 and Q0091 and Annual Wellness Visits AWV G0438 and G0439
As we are all aware, Medicare now allows for the Annual Wellness Visit (AWV) G0438 or subsequent AWV G0439, but how does this relate to an annual Well Woman Exam? IT DOESN’T.
An annual Well Woman Exam is a completely separate evaluation and management service from an AWV, and unless the provider specifically evaluates a patient for both the AWV and a Well Woman Exam, the AWV should not be billed out. So, how does a provider bill out for an annual Well Woman Exam for a patient covered by Medicare? Let’s discuss the components of the Routine Annual Preventive Physical Exam (sometimes call an Annual Exam) first.
What does an Annual Exam include?
Preventive Medicine Service codes are defined by the CPT book as evaluation or 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.
The purpose of the annual exam includes screening for disease, assessing risk of future medical problems, promoting a healthy lifestyle, and updating vaccinations. Aspects of the annual exam may include all or some of the following:
1. Review of History
2. Checking Vital Signs
3. General Appearance
4. Heart Exam
5. Lung Exam
6. Head and Neck Exam
7. Abdominal Exam
8. Neurological Exam
9. Dermatological Exam
10. Extremities Exam
11. Males: Testicular and Prostate Exams
12. Females: Breast and Pelvic Exams
13. Counseling
14. Routine Laboratory Tests
15. Immunizations
Does an Annual Exam also include a Well Woman Exam?
Yes. The Routine Annual Preventive Physical Exam also includes the components of a Well Woman Exam. If a patient is seen by her primary care physician (PCP) for an annual, the provider will also include the pelvic and breast exam and a Pap smear collection. If the patient elects to have the Well Woman Exam performed by her gynecologist, the PCP must document that the pelvic and breast exams and pap smear collection were deferred, and will be performed by a gynecologist.
Incorrect Billing Procedures
1. What if you run out of time? If the patient is seen for an annual and the Well Woman Exam portions are not done during the same visit, the provider may need to see the patient again in order to complete the comprehensive exam. This second visit is merely a continuation, and it is not billable.
2. Can you bill an annual with Z01.411, Encounter for gynecological examination (general) (routine) with abnormal findings, or Z01.419, Encounter for gynecological examination (general) (routine) without abnormal findings, and get paid separately? No. If you have already billed out an annual in a given year (Z00.00, Encounter for general adult medical examination without abnormal findings or Z00.01, Encounter for general adult medical exam with abnormal findings), then you cannot charge another annual with a different diagnosis.
3. What if the patient did not want the Well Woman Exam portions done during the regular annual? If the patient did not want the pelvic/breast exam and pap smear collection during the routine physical, but later decided to not see the gynecologist and came back for these screenings, you still cannot bill for these separately. They are already included in the annual. The patient may be seen, but it cannot be billed.
Requirements of Coding and Billing an Annual Well Woman Exam to Medicare
Medicare does not cover preventive services, such as an annual (besides the AWV), but certain Well Woman Exam screenings are reimbursed either every two years or annually.
Covered Services
Medicare covers the following screening exams in conjunction with a Well Woman Exam:
1. G0101 Cervical or Vaginal Cancer Screening; Pelvic and Clinic Breast Examination
a. G0101 is reimbursed by Medicare every two years unless the patient is considered high risk, and then it is allowed on an annual basis. You must document a minimum of 7 of the 11 elements.
b. According to the CMS website, the following ICD-10-CM codes are billable with G0101. Select the appropriate codes.
Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings [Use additional code(s) to identify abnormal findings]Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
Z11.51 Encounter for screening for HPV (primary)
Z12.4 Encounter for screening for malignant neoplasm of cervix
Z12.72 Encounter for screening for malignant neoplasm of vagina
Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs
Z12.89 Encounter for screening for malignant neoplasm of other sites
Z72.51 High-risk heterosexual behavior
Z72.52 High-risk homosexual behavior
Z72.53 High-risk bisexual behavior
Z77.29 Contact with and (suspected) exposure to other hazardous substances
Z77.9 Other contact with and (suspected) exposures hazardous to health
Z91.89 Other specified personal risk factors, not elsewhere classified
Z92.89 Personal history of other medical treatment
2. Q0091 Screening Papanicolaou Smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory
Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings [Use additional code(s) to identify abnormal findings]Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
Z11.51 Encounter for screening for HPV (primary)
Z12.4 Encounter for screening for malignant neoplasm of cervix
Z12.72 Encounter for screening for malignant neoplasm of vagina
Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs
Z12.89 Encounter for screening for malignant neoplasm of other sites
Z72.51 High-risk heterosexual behavior
Z72.52 High-risk homosexual behavior
Z72.53 High-risk bisexual behavior
Z77.29 Contact with and (suspected) exposure to other hazardous substances
Z77.9 Other contact with and (suspected) exposures hazardous to health
Z91.89 Other specified personal risk factors, not elsewhere classified
Z92.89 Personal history of other medical treatment
a. Q0091 is reimbursed by Medicare every two years unless the patient is considered high risk, and then it is allowed on an annual basis.
b. Per the CMS website, the following ICD-10-CM Codes are billable with Q0091. Select the appropriate codes.
3. 82270 Fecal Occult Blood Test
a. 82270 can be billed on an annual basis.
b. Per the CMS website, the appropriate code varies by carrier. An applicable code is Z12.10 Special Screening for Malignant Neoplasms; Colon.
For complete information see Medicare’s Screening Pap Tests & Pelvic Exams MLN Booklet.
High-Risk Factors and Frequency
High-Risk Factors determine whether or not a patient may have the G0101 and Q0091 on an annual basis. If a patient is considered high risk, then these screening tests may be done annually.
According to the CMS website, the following factors are listed as high-risk factors for screening pap smears and pelvic exams:
1. Cervical High-Risk Factors
a. Early-onset of sexual activity (under 16 years of age)
b. Multiple sexual partners (five or more in a lifetime)
c. History of a sexually transmitted disease (including HIV infection)
d. Fewer than three negative pap smears within the previous 7 years
2. Vaginal Cancer High-Risk Factors: DES (diethylstilbestrol) exposed daughters of women who took DES during pregnancy
3. Personal History of Health Hazards: If a patient has a specified personal history presenting hazards to health then apply the appropriate diagnosis codes considered high risk. This makes the patient eligible for the yearly G0101 and Q0091.
Advance Beneficiary Notices (ABNs)
An Advance Beneficiary Notice is a Medicare Waiver of Liability that providers are required to give a Medicare patient for services provided that may not be covered or considered medically necessary. ABNs do not apply to services that are specifically excluded from Medicare coverage, such as a Routine Annual Preventative Physical Exam.
A completed and signed ABN is key for reimbursement. It also notifies Medicare that the patient acknowledges that certain procedures were provided and that the patient will be personally responsible for full payment if Medicare denies payment for a specific procedure or treatment. If there is no signed ABN then you cannot bill the patient and it must be written off if denied by Medicare (translation: Free Services, Lost Revenue).
ABN Criteria
1. The ABN must be given to the patient prior to any provided service or procedure.
2. The patient’s name, specific service, and estimated charge amount must be listed on the ABN.
3. An ABN cannot be given to a patient who is under duress or requires emergency treatment.
4. Check for specific criteria and download the form at http://www.cms.gov/BNI/02_ABN.asp
Appropriate Medicare Modifiers
Certain Medicare modifiers are required when billing with an ABN.
1. GA Modifier: Waiver of Liability Statement Issued as Required by Payer Policy. This modifier indicates that an ABN is on file, and allows the provider to bill the patient if not covered by Medicare.
2. GX Modifier: Notice of Liability Issued, Voluntary Under Payer Policy. Report this modifier only to indicate that a voluntary ABN was issued for services that are not covered.
3. GY Modifier: Notice of Liability Not Issued, Not Required Under Payer Policy. This modifier is used to obtain a denial on a non-covered service. Use this modifier to notify Medicare that you know this service is excluded.
4. GZ Modifier: Item or Service Expected to Be Denied as Not Reasonable and Necessary. This modifier should be applied when an ABN may be required, but was not obtained.
Billing a Well Woman Exam
Fee for Service
Because specific Well Woman screening components of the routine annual exam are covered by Medicare, these are billed out separately. These screenings are carved out from the provider’s usual fee for preventive service because they are allowable and reimbursable by Medicare. The remaining balance is the patient’s financial responsibility. The total fee does not change, only how it is billed and who pays.
The G0101 and the Q0091 are the services that are reimbursed and carved out of the regular annual fee. The Medicare reimbursement for the G & Q and patient portion equal the same annual fee that a non-Medicare patient would be charged.
For example, if the fee for an annual for a non-Medicare patient is $235.00, this is the breakdown for a Medicare patient:
| CODE | DESCRIPTION | FEE |
| 99397 | Routine Annual Exam – Established pt 65 and older | $142.35 |
| G0101 | Pelvic/Breast Exam | $41.96 |
| Q0091 | Pap smear Collection | $50.69 |
| TOTAL | $235.00 |
It is the same original fee but billed out differently. For additional clarification, please refer to ACOG’s Medicare Screening Services PDF.
Billing Medicare
Following is an example of a typical Well Woman Exam without abnormal finding with a signed ABN that is billed out to Medicare:
| Code | Modifier | Diagnosis |
| 99397 | GY | Z01.419 |
| G0101 | GA | Z01.419 |
| Q0091 | GA | Z11.51 |
| 82270 | GA | Z12.10 |
| 81002 | GY | Z01.419 |
Reference
Medicare billing policies are constantly changing at CMS and with your local carrier, so before you do anything, check with them and your coding specialist to make sure you are billing correctly.
The CMS website has a quick reference guide for Medicare Preventive Services that lists applicable tests, diagnoses, and frequencies. Check it out for more information.
CPT copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Good morning Manny,
I am an inpatient coder needless to say EM coding is new to me. I have a question regarding the Well Woman Exam some EM educators’ states that among the 7 elements breast must be one of them. However, some states that Medicare no longer requires a breast exam as part of the well woman exam. Which is true?
Hello Manny,
First, I want to thank you for helping so many people! Your expertise is greatly appreciated! I reviewed the article above and comments as well as many other articles but I could not locate a billing code to be used for a Medicare-approved doctor’s office preventative-type visit that occurs within the first 12 months of a person being on Medicare. I have the typical billing issue: for my Breast and Pelvic Exam, code 99397 was used and it was denied by Medicare (I have a bill for $265). In addition, the HPV test portion (code 87624 – Detection Test by Nucleic Acid for HPV) of my Pap smear was denied for payment (I have a bill from Lab Corp for $87.87), whereas the regular part of the Pap screening procedure (code G0145 – Screening Cytopathology, Cervical or Vaginal) was approved for payment. I had spent hours in advance of my first “Medicare” appointment researching billing codes in an effort to prevent billing issues – all to no avail. I called Medicare and was told my provider should have billed the code as a “Welcome to Medicare Preventative Visit” (applicable for first 12 months of being on Medicare) but they could not give me the code. They told me my provider should know the code or the provider can call them for assistance. My provider seemed clueless when I asked them about this. After reading so much about the proper Medicare billing codes, I am wondering if there really is a special billing code to be used for a preventative-type exam that occurs within the first 12 months of being on Medicare. Have you ever heard of a different billing code to be used within the first 12 months of being on Medicare? If there is no such thing, perhaps my provider simply needs to resubmit the bill using the Medicare-approved codes G0101 for the Breast and Pelvic Exam and Q0091 for the Pap Smear (and I’m not sure if I need to have my provider or Lab Corp resubmit for the Pap Smear bill). Thanks in advance for your assistance!
We have a patient who has Commercial Insurance primary and Medicare secondary. We billed out the 99397 to commercial but when that claim was sent to Medicare is was denied. I know Medicare does not cover the 99397 code, so are we supposed to change it to the G0010 & Q0091? Medicare stated that if our codes do not match from the primary EOB then they will deny the claim . I am confused on how to submit this claim to Medicare for payment.
Hi! Billing gyn coder here and I’m so glad to have found this page! Do you know if Medicare Advantage Plans work the same way for 99397 and the G0101, most specifically Florida Blue Medicare Advantage? We try to bill our annuals with a diagnosis (if pt presents with a problem while having her annual) and E/M code to save our patients money by not having them pay for costly 99397 gyn annuals that are not covered by Medicare. But now, we are running into pts who balk at paying their copay with the Fl Blue Medicare Advantage plan because they think it should be covered at 100% because the ins company tells them this is so. What they do not understand is only the G0101 code is covered with an allowable of around $33.00 and that if we Bill a 99397 (which we are in our rights to do I believe?) then they will then owe even more of a balance than their $45 copay for office visits. If I have read everything correctly here on this site that for a well woman gyn exam with breast exam and pelvic exam, we would code a 99397 at $200 and a G0101 which would get paid $33.00. We would then subtract the $33 amount paid by the insurance from the $200 99397 fee and the pt would then get a bill for $167? Does this sound correct? Thank you in advance!
Agreed!! Thank you
Is a gynecologist allowed to use G0438 or G0439 instead of 99397 or 99387?
The billing office of my doctor tells me Medicare does not allow it?
VERY NICE ARTICLE
hi, i called the billing dept and never saw a bill, but u still feel it is wrong, did not have a pap just a breast exam and pelvic.
not using hm any more and also my sister in law in albany had the same thing happen and they put her on collection, really, $300 for an exam, Medicare patient.
Not fair
Medicare never pays for routine or annual exams in the 99xxx code range. This is clear in all the information that is given about IPPE and AWV. Medicare only pays for problem-oriented visits and approved preventive services. It is inappropriate to have the patient sign an ABN in these cases.
My gyn billed Medicare for a 99397,(not paid) I signed an ABN but fee was not on form, I later got a bill for $300.00!, really, do they think I and all other women are going to pay $300.00. What is the rule here? Can they really bill me $300?
Regi Chase
Hi Regi —
The short answer is YES.
Unfortunately, Medicare does not cover a routine physical exam and technically the practice does not have to provide you with and ABN since it is a non-covered service. That said, its pretty crummy they did not tell you the cost of the service beforehand so that you could make the choice of having the physical or not.
Did you have a pap and pelvic exam? How about a pap smear? Those two items are part of the physical but can be carved out for payment from Medicare. What Medicare pays is then subtracted from the $300. See my example in the blog post on how this is calculated. If $300 is the full fee for the service, once the two carve outs are taken you should owe around $210. A little better.
I sure wish practices would make it clear to patients what Medicare pays for and doesn’t pay for.
You may have to call the GYN’s billing department to see how they billed the visit. Hope this helps. –Manny
What type of code edit could be used for the following rule? Medicare Part B covers a screening Pap smear for women for the early detection
of cervical cancer but will not pay for an E/M service for the patient on the same day.
I’m a 62-years-old, disabled woman, and have Medicare part A, B and D. I went to a gynecologist for pap smear, breast and pelvic check. She billed me under the code 99396/GY and Medicare rejected the claim. Was the rejection due to the GY modifier she put in? The doctor no longer works in the clinic (the department was closed by the hospital) and the billing staff told me they couldn’t change the code written by the doctor. I appealed to Medicare but was rejected again because of the code 99396/GY. What can I do to reappeal and make Medicare cover the preventative service?
Thanks!
Hi Jade —
Sounds like the doctor and the billing department don’t know how to bill a physical and well woman exam to Medicare. You would be surprised how many medical practices don’t know how to code the visit properly.
First, let me start by telling you that routine physicals are never covered by Medicare. The code the doctor used 99396 denied appropriately and you are responsible for the payment. If you have secondary insurance it may cover the visit but most do not.
That said, based on what the services you indicated were performed, the visit was coded incorrectly for a Medicare patient.
While it is true that Medicare will not pay for the physical they do pay for two components of the physical, the pap smear and breast and pelvic exam. Medicare “carves out” these service from the physical and pays for them once every two years.
Since Medicare pays for these two service that are part of a physical, Medicare requires that the doctor reduces the price of the physical by what Medicare pays.
For example, if the fee for the non-covered physical is $200, the doctor should subtract the $50 Medicare pays for the pap and the $40 for the breast and pelvic exam from the physical fee. This leaves a balance of $110 that the doctor can collect for the physical.
$200 Physical – $50 Pap – $40 B & P Exam = $110 Billable to Patient/90Paid by Medicare
So the claim should have been coded as follows based on your question:
99396-GY Routine Physical Exam
Q0091 Pap Smear
G0101 Breast and Pelvic Exam
Now the GY modifier states that a Notice of Liability was not issued nor was it required under Medicare policy. This modifier is used to obtain a denial on a Medicare non-covered service. This modifier is used to notify Medicare that service is excluded and that the medical practice expects a denial. The patient will then receive an Explanation of Benefits that clearly states they are responsible for the charges.
The Notice of Liability is also called an Advanced Beneficiary Notice (ABN). This is a document given to the patient prior to service being rendered that tells the patient they may be responsible for payment. But in the case of 99396 is not required to be given to you. I always tell practices it’s a good idea to give it patients so they know ahead of time if a service may cost them personally. It’s just good customer service. Sorry they didn’t give you one.
So the GY modifier was appropriate since your physical was not covered. They could of even left it off as it is an optional midifier and the result would have been the same.
Appealing to Medicare is a waste of time as Medicare will never cover this claim.
The best you can do is to have the billing department pull the chart notes of the visit and see if the doctor documented your visit sufficiently to be able to rebill with the proper codes. You will still be responsible for a good chunk of payment but some of the visit should be covered and paid for by Medicare which is better tan have to pay the entire amount. That will be a hard battle since it looks like they already don’t know what they are doing.
Here are a couple of resources that may help in your battle. Best wishes. –Manny
https://www.capturebilling.com/medicare-billing-well-woman-exam-g0101-q0091/
https://www.capturebilling.com/wp-content/uploads/2015/06/Capture-Billing-Well-Woman-Exam-G0101-Q0091.pdf
Manny,
Thanks very much for the quick reply and detailed information/explanation! I will contact the billing department and reappeal the case to Medicare.
Sincerely,
Jade H
Informative suggestions ! I was fascinated by the points ! Does anyone know if my business might be able to grab a sample form document to fill out ?
How do you code for a patient that needs to get her yearly mammogram scrip but refuse the examination because she is only covered every two years.
I truly appreciate all of the valuable Billing information.
Thank you so much!
Paula Cenac
I received an annual well exam at my gynecologist and while there I complaint of an irritating vaginal discharge and said I believe I had a vaginal infection. A vag exam was done and specimens taken of the discharge. It was positive and a prescriptions was ordered.
I was coded as follows: 99397GY, G0101GA
I was billed for the preventive service. Why? Doc would not have found the infection had she not done the exam. How should this have been coded or handled for medicare to pay.
Hi Phyllis —
This is a great question. I am going to answer your question in a blog post because I think other people would like to know the answer. The way doctors code and bill can be confusing so maybe I can shed a little light on the subject. Give me a couple of days and I will have your answer for you. — Manny
Did I miss your reply?
Still working on the post. Looks like next week now. Will keep you posted.
I just started with medicare A and Mutual of Omaha supplement. First let me say I’m confused. I went to my primary for a check up I have end stage renal disease. I then went to my Gynecologist for a pap she does NO blood work just the pap and breast exam..I ended up paying 200.00 to her for her bill. Why? You can’t call this a physical because there’s no blood drawn just what I mentioned.Is there anything I can do to not pay this. My medical bills are piling up. I need help on how to make this work with out a bill.
If you have a routine annual pelvic exam done, how is it billed? What is the difference between a routine annual pelvic exam and a wellness visit?
Hi Sylvia. A pelvic exam is actually included as part of the annual routine physical exam. You would bill it using your preventive medicine evaluation and management CPT codes 99384-99387 or 99394-99397. An Annual Wellness Visit is just a series of question that are asked of the patient. A nurse can perform the AWV as there is no physical examination.
Mr. Olivers,
Can we bill Medicare for IPPE (G0402)and perform Q0091&G0101 dx: V15.89 (high risk due to not had it done for the last seven years)during the same visit? Do I need modifier 25 append to IPPE?
Mr. Olivers,
Can we bill Medicare for IPPE (G0402)and perform Q0091&G0101 dx: V15.89 (high risk due to not had it done for the last seven years)during the same visit? Do I need modifier 25 append to IPPE?
Hello Manny,
What is the correct way to bill these CPT codes?
G0439, Q0091,G0328,87210 the office did not put any modifiers on and submitted to Medicare.
CPT codes G0439 & Q0091 paid through Medicare and the other two G0328 & 87210 rejected. Is the QW modifier appropriate and will Medicare process payment for these codes? Or are these included in the basic service/bundled?
Please help, just started the A/R for this OB/GYN and trying to get the hang of things
What were the exact denial reasons for the rejected codes? Do you have a CLIA number and was it submitted with the claim. Need a little more information.
Hello Manny,
A common visit for a Medicare patient is when the come in for multiple things in one visit. For example a PAP, medicine refill and a referral form for a follow up to an abnormal Mammogram etc. Since the preventative physical is not billable but the Doctors find it prudent to do a physical. What codes might we use so the patient is not given a 250 dollar bill?
Warm Regards
Natalie
A prior OBGYN preformed a “failed”,balloon oblation which left me with ASHERMANS syndrome.
I ended up having Hashimotos, so he was just treating the symptoms of that disease.
My new OBGYN said she had to preform a D&C in the hospital, because my uterus is “like cobwebs”,so she had trouble getting “cells” from my uterus.
Does that not m
ake me “high risk?”
She said: “If you see one drop of blood I am giving you a hysterectomy”.
Last year, she gave me no exam. I just went in and sat on the table, she came in, said, “you do not need it this year”, and I left.
What is that?
I feel dismissed and misdiagnosed, and now the colleague relationship, seems more important than my health.
54 years young and no pep smear for you!
Medicare became primary after a DRUNK DRIVER maimed me and disabled me from working. I have had 2 cervical fusions, the first one broke.
Now I am being re-victimized by crappy insurance, and it is so obvious that we are overlooked.
Rushed, dismissive appointments.
They diagnosed me over the phone, with some estrogen pill to shoot inside myself.
That did nothing so the PAIN continued and I called back after suffering for 40 days. Finally, they had me come in for an actual exam, and I had an infection!
Saving money? Maybe, but at the cost of leaving people misdiagnosed and stabbing in the dark for a “cure”?
PAIN. Do we have to call and cry and scream to get care now? I can do that if need be, but I figured acting like an adult, should get me the care I had been used to.
It is all rather sloppy care, and they make you know, where you now fall, on the healthcare train.
CABOOSE~
my doctors office says I have to pay for the office visit in the annual wellness visit. From what I’m reading I think if they used the correct code it would be covered by Medicare. they used code 99397-gy which was not covered and code g0101-ga which was covered. Please help.
I have a question regarding the V15.89 dx code. We have a LOT of our Medicare patients that refuse to answer the sexual history questions, therefore the providers can’t honestly say if they are high risk or not. Can I still use the V15.89 since the patient refuses to provide the information needed to determine if they need the well woman exam annually or biannually?
Angie if the patients are refusing to answer the sexual history section in your health questionnaire, then you should not utilize V15.89 on any claims you submit to Medicare. However if, based on the discussion between the provider and the patient, there is documentation in the patient’s health history from the provider about the patient’s high risk status then the V15.89 dx code could be applied.
Are your docs asking about sexual history if the patient does not answer the questionnaire? They should be.
When using the -GY modifier for services not covered by Medicare, does the secondary insurance companies typically pay for the CPT with the -GY modifier, or do they also state it would be patient responsibility?
Janie that depends. Some secondaries do cover some services and procedures that Medicare does not. It really all depends on the individual policy the patient has. So even if you put a GY modifier it may pay. . . or not.
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Mr. Oliverez,
I was wondering about the difference between the 99387 and G0439. Our provider does not see many Medicare patients. You stated “They are two distinct services. You can always bill both if your doc did both services”. How are they different?
Here are the requirements for the twp services.
A Preventive Medicine Services of Routine Physical Exam 99387/99397 consists of:
– Review of Systems
– Past Medical, Family and Social Histories
– Age and Gender Appropriate Comprehensive Physical Exam
– Counseling/anticipatory guidance/risk factor interventions
The Medicare Annual Wellness Visit G0438/G0439 consists of:
– 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
Note that there is no review of systems or physical exam for an AWV. Additionally you must cover and document all elements of the AWV to be billable.
I am billing a Medicare pt for V72.31 and V70.0, should I bill with a 99387 and/or the G0439? We also billed the G0101 with dx V76.2. I know Medicare will deny the 99387, but could we get paid for the G0439?
Hello Maria —
As to which code to bill, a 99387 or a G0439, what service was performed by the physician, a New Patient Routine Physical Exam(99387) or a Subsequent Annual Wellness Visit(G0439)? They are two distinct services. You can always bill both if your doc did both services.
Billing G0101 with V76.2 seems appropriate. Did you collect a pap smear also. If so you could bill Q0091 with V76.2. Yes Medicare will not cover 99387 but you can get paid for it. Medicare allows you to bill the patient for a Routine Physical Exam 99387/99397. You just have to carve-out any payment from Medicare for G0101 and Q0091 from what you bill the patient for the 99387.
We bill Medicare patient for the Routine Physical Exam all the time with now problem. You don’t even need to have them sign an ABN, although I strongly suggest that you do to let them know they will be getting a bill.
Hope this helps –Manny
I am new to billing, my question is – currently we are billing the Q0091 for a male pap. Obviously this is for women only. How can we bill properly for the visit and male pap? I was told to use the 99000. Isn’t that too vague of a code for Miscellaneous Services? Will 2014 CPT’s have a male pap code so we can be reimbursed properly from Medicare? I have hundreds of denials for this code and need to get these billed properly for Medicare. Thank you!
Craig
I have patients that have Medicare primary and Medicaid as secondary, how do I bill the claims to Medicaid Ohio when Medicare denied the claim. I know the Q0091 and G0101 are Medicare codes only, so would I use the S0612 to bill to Medicaid? Also i billed CPT 99396, G0101, and Q0091 to Medicare and was only paid on the G and Q code, can I still bill the 99396 to Medicaid? After I crosswalk the code to use a covered charge?
Maria —
You would still bill the Q0091 and G0101 but in our experience usually what reimbursement we get from Medicare is it. My bigger question is why were the codes denied. Medicare usually pays those codes with no problems. Was there a frequency issue. If so there is no chance Medicaid will pay. Did you get an ABN signed to be able to bill the patient? Also typically we see 99397(65 years and older) and not 99396 (40-64 years). Either way Medicare will not cover these preventative care visits. They can be, and should be, billed directly to the patient once the Q & G codes are carved out for pricing.
Can we bill an AWV and an OV the same same day. If so, how should we bill my example
G0101-GA v76.2
Q0091 v76.2
99213-25 627.4
Tarnesha —
Yes you can bill an Office Visit on the same day as the AWV. Based on what you mentioned and without seeing any notes, one way may be, if properly documented with an ABN and if you did a full physical exam:
99387-GY V70.0
G0438-GA V70.0
99213-25 627.4
G0101-GA V76.2
Q0091-GA V76.2
Mr Oliverez
I am new to GYN billing and having a terrible time getting Medicare claims to be accurate. I have billed the G0101 and Q0091 codes as appropriate per the notes and get paid for these. I have started having the front desk have patients sign ABNs. My question lies within the visit code either a 99387 or 99397 with the ABN modifier according to what I have read. I have also begun billing G0439 on some cases.
Scenerio:
Patient comes in for annual well woman check. ABN is signed. Physician performs a review of all systems, breast and pelvic exam (pap may or may not be obtained).
Would I not bill the G0439, GY ; G0101 ; Q0091? or instead of G0439 would I bill the 99387 code?
This has been very frustrating to me and I am looking for the correct, acceptable way to bill this.
Thank you,
Venita Milburn
Hello Venita and thanks for your question. First I want to make sure that we are on the same page. CPT codes 99387 and 99397 are not covered by Medicare and are billable to the patient. According to Medicare the patient doesn’t even need to sign an ABN for these services but as a practical matter we do have our practices present a “Voluntary ABN” for these services to the patient. Its good customer service to let them know they will be getting a bill.
A G0439 and a 99387 are not the same services and you can bill them both together if both services are done so in your scenario I am not sure how to bill it without seeing the notes. But lest say that the doctor performed a full routine physical along with a subsequent Annual Wellness Visit on an existing Medicare patient. Plus a pap and breast 7 pelvic exam and on top of that the patient had a sore throat that turned out to be strep and the doc prescribed an antibiotic.
this is how I would bill the visit:
99387 V70.0 $165.96
G0439 V70.0 111.94
99213-25 034.0 72.81
G0101 V72.31 38.11
Q0091 V72.31 45.93
TOTAL $434.75
Since the routine physical is not covered Medicare has you care out the G0101 and Q0091 reimbursements they will make from what you charge the patient for the 99387. So if you charge $250 for 99387 you must subtract the payments from the G0101, $38.11 , and Q0091, $45.93 , since they are included in 99387 and bill collect from the patient $165.96. I used Medicare national pricing.
So in my scenario you would get reimbursed from Medicare and the patient a total of $434.75 for the visit.
Did you download my Billing a Well Woman Exam to Medicare report? If not CLICK HERE to download it. It contains more detailed information.
Not sure if this helps or is more confusing. Please let me know — Manny
Thank you this was very helpful.
Venita
If I have a nurse who is doing this and she codes:
99213
Q0091
V70.0
V72.31
401.1
What is the correct way a nurse practitioner should be billing for this?
Dori — A nurse practitioner and a doctor would bill the same way. Just based on the codes you provided without any documentations this is how I would bill the visit for this Medicare patient:
99213 401.1
Q0091 V72.31
To be sure I would look at the chart note. Hope this helps — Manny
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I am a year into this billing job and we don’t have many medicare patients, but I seem to be having problems with sending claims out to medicare and them receiving them. Can you please guide me to get the claims address and a GOOD phone number for me to ask questions.
Thank you,
Norma
Norma the information you need should be on your local Medicare website. Where are you located? What is the name of the local Medicare carrier?
How would i bill for an annual breast exam without the pelvic exam?
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In our Comprehensive Breast Center, our Nurse Navigation program would like to create a program for clinical self breast exams. Is there a CPT code for this?
Thank you!
I have G0438 with a 25 modifier Q0091 no modifier and G0101 with 59 modifier no GA on claim and the V72.31 was the dx codes. Bravo rejected G0101 wanted the claim resubmitted with appropriate modifier or missing modifier. Is there another modifer that can be used in order to get claim processed?
You know Linda I think the modifiers are what is messing up the claim. We do not use modifiers on these codes when we submit claims. Check with your local Medicare carrier on the specifics in your jursidiction on how to properly bill these codes and try again.
The patient was supposed to have a wellness exam G0439 instead she had a 99397 was coded. She also had a pap. Is the patient now responsible?
Elizabeth that would depend. By only coding 99397 your doc is stating two things:
1. The patient did not have an Annual Wellness Visit (AWV)
2. A Complete Routine Physical Examination was performed (99397)
Since your have questions on the code that was billed you should take a look at the documentation for the visit. Maybe there was an AWV performed and a 99397. In that case you could bill the G0439 (Subsequent AWV) and the 99397 together. Maybe it was coded wrong and it really should be G0439. There is no way to know without reviewing the chart notes. The notes is where I would start looking. Remember that an AWV is not a Routine Physical and cannot be coded as such.
So if it turns out to be a 99397 then the patient would be responsible. The Pap should be billable to Medicare so don't forget to carve-out the price of the Pap (Q0091) from the 99397 before you would bill the patient. Also get your Medicare patients to sign an Advanced Beneficiary Notice (ABN) for applicable service.
The CMS website has a quick reference guide for Medicare Preventive Services which lists applicable tests, diagnoses and frequencies. CLICK HERE to get it. –Manny
I dont have or do twtter. How else can I communicate with Manny if I have other questions? I'm working for a PCP office for the first time & lost on alot of the billing.
Go to Facebook or give me a call.
When billing Q0091, can dx V15.89 be a primary dx?
We have billed using V15.89 as the primary diagnosis followed by the ICD-9 code giving the reason for the high risk and have gotten paid.
Can someone help me,
We are going to start providing Clinical Breast Exams prior to mammograms in the mammography department and want to know how we can bill for this service.
What is the billing code to be used for a physical breast exam only?
Can a mammography technologist who is certified to perform Clinical Breast Exams bill for the physical breast exam?
If so what billing code should be used?
and what diagnosis codes are appropriate to use?
(We are located in Missouri if that matters)
If nobody knows this answer do you know where I can find the answer?
If Medicare does not pay for 99387 & 99397, what would be the purpose of billing for those codes if Medicare does cover the annual wellness visits when billed using codes G0438 and G0439?
The Annual Wellness Visit codes G0438 and G0439 do not include the components of a Routine Preventative Exam. Therefore you can bill for both at the same time if the provider performs both services and documents them accordingly. Cori, you are correct that 99387 and 99397 are non-covered services and Medicare not will pay for them, however, you are still allowed to bill for the Routine Exam. You do not need an ABN to bill the patient as it is not required by Medicare for most preventive services but we do have our practices give a voluntary ABN to their patients so that they know the exam will ultimately be their financial responsibility. Additionally, several secondary insurance companies do pay for the routine annual exam even though Medicare will not.
thanks for giving information
Are paps cut off at age 65?
Michelle-
No; many of our doctors continue to bill paps after age 65 for their female Medicare patients, and Medicare has been paying for these. As always, check with your local Medicare carrier on any requirements for billing for pap smears.
I have to bill a wellness exam, how should I code that?
Krissa are you asking about a Routine Well Exam? If so, that would be billed using a 99387 or 99397 depending if it is a new patient or existing patient. A diagnosis code of V70.0, routine physical exam, would be appropriate. Routine exams are a non-covered service by Medicare so the patient would be responsible for the entire amount. There is a calculation if you are also doing a Pap, pelvic and breast exam where you carve out those procedures and bill them separate from the routine exam. You should also add a GZ modifier.
Come back to the website in a couple of weeks. We are giving away a booklet on how to bill a routine exam with a well-woman exam to Medicare. Also, look at other posts on our website about billing Medicare. If you were asking about the Annual Wellness Visit (AWV) check out my post, https://www.capturebilling.com/medicare-g0438-g0439-two-new-annual-wellness-visit-codes/. If you were asking about the Welcome to Medicare exam see https://www.capturebilling.com/welcome-to-medicare-visit-ippe/ .
The best thing you can do is go to your local Medicare carrier website. There you will find information on exactly how to bill for these and other procedures.
If a patient is having their Medicare annual exam at the same time would you bill out this way:
G0402
Q0091GA
G0101GA
YES. The parameters of the G0402, Welcome to Medicare exam, are very specific. Remember a G0402 is not an "annual exam”. The G & Q codes can be billed with the G0402. The GA signifies you have a valid ABN on file. Billing as you’ve listed is appropriate as long as you have met the docmentation and medical necessity requirements.
Hi Manny,
Why would you append a GA modifier on these claims, Medicare does cover for these services. G
Great question. Yes Medicare does cover Q0091 and G0101 but there are some restrictions. Medicare states these test can be performed . . .
\”Annually if at high risk for developing cervical or vaginal cancer, or childbearing age with abnormal Pap test within
past 3 years. Every 24 months for all other women.\”
Let\’s say a woman comes to your practice as a new patient and you perform and bill the G0101, Pelvic and Breast Exam and Q0091, Pap smear, and do not have an ABN signed because it is a covered service. You then submit the claim to Medicare and two weeks later you receive a denial from Medicare stating the procedures are not covered due to coverage limitations and you cannot bill the patient because you do not have an ABN on file.
So what happened? It\’s a covered service right?
Well that last well woman exam the patient thought they had 3 years ago was actually 22 months ago. As you can see Medicare only coveres these services every 24 months. Thus a denial and the service becomes non-covered.
If there was an ABN on file, which you would have indicated by using the GA modifier, Medicare on the EOB would state that the service could be billed to the patient.
No ABN and GA modifier in this senerio would lead to no payment for the service you physician provided.
We advise all our practice to obtain an ABN and to make sure that the ABN is filled out properly to be valid.
Please let me know if this helps. -Manny
Does it have to be exactly 365 days at least to bill the annual codes by a PCP/internal medicine like me? Examples if I saw and billed a annual visit and billed the 99397 and G0438 2/13/13 and then bill for it 1/2/2014 will I be paid? PS this a very useful and informative site. Thanks. Dr Kim
Dr. Kim thank you for your kind words.
Yes you must wait one full year before before billing another Annual Wellness Visit. So if you billed a 99397 with a G0439 on January 2nd then you will not be paid for the AWV as it was done within a year of doing the initial AWV G0438. Of course you still have the fee you collected from the patient for the 99397 routine physical exam. You did collect that correct?
Remember the G0101 and the Q0091 are Medicare codes to use when you carve out the breast/pelvic exam and PAP from the well exam. For regular commercial insurance there is no carve out and the breast/pelvic exam along with the pap smear collection are included in 99397. You can however bill for the lab specimen transfer fee 99000 to send the sample to the lab and for the wet preps if you do them.
Manny,
We are looking into doing Well Women's pelvic and breast exams in our office. We are a PCP office.
Will the insurance companies combine 99397 and G0101 as one procedure..but will they pay the PAP collection along with the 99397.
Hi, I had billed G0101 and Q0091 in 06/03/2014 to Medicare and it was paid. then same I billed on 10/23/15 but medicare denied as maximum benefit has reached. Does Medicare pay for these services once in a year or once in every two year..can you please help?