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.
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.
Hello,
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!
Thanks!!!
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 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)]
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.
Hi Manny,
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.
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.
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.
Regards
Tim
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
tHANKS
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.
Hi Manny,
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
Hi,
Do not use the injection diagnosis with the office visit.
Hi,
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
Yes
Thanks Tawanna for your contribution! We really have a great community. People helping others is what it’s all about.
Manny,
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
how about
99214 -25
99397
93000
j1020
96372
they will pay 96372 and deny 99397, pls help
you need 59 on the 93000 and the 96372
Thank you
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
Hello ,
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
Hi Manny,
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!
Constance
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?
Hi Manny,
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?
hi Manny,
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
Hi Manny,
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.
Hi Manny,
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?
Thanks!
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.
Hi Manny,
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.
Thank you so much for your help!
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
or
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.
Hi Eileen,
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
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
Leah,
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.
Hi Manny,
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)?
Thanks!
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.
Hi Manny,
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.
hi
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
Marcie,
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.
Manny,
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.
THANK YOU,
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
Hope this helps.
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.
per CMS:
“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
THANKYOU
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.
Thanks.
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.
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.
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
VERONICA,
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.
Hello Manny,
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
HI,
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?
Thanks
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
Manny,
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
Manny,
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?
Manny,
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
Sir,
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 ?
Thanks
Manny,
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.
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.
Karen
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.
Hello Manny,
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?
Thank you!
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.
Manny,
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
Hey manny,
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.
Hope this helps — Manny
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
Does this help?
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
Hi 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
Thanks
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?
Thank you!
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
Let me know if this helps –Manny
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?
Hi Manny,
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
Thank you
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
Sally,
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
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.
Hope this helps.
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
Thanks.
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.