Medicare G0438 - G0439: Annual Wellness Visit Codes
Health Insurance Companies Process 1 in 5 Claims Wrong.

Medicare G0438 – G0439: Two Annual Wellness Visit Codes

Medicare Benefit: Annual Wellness Visits Covered

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

G0438 Annual Wellness Visit, Initial (AWV)

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

G0439 Annual Wellness Visit, Subsequent (AWV)

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

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

What is included in an Initial AWV with PPPS?

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

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

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

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

Leave a Comment

Your email address will not be published. Required fields are marked *

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

  1. 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

  2. 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.

  3. Laura F. Villareal

    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.

  4. 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

  5. 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.

  6. susie stevenson

    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

  7. susie stevenson

    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

  8. 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?

  9. 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

  10. 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

  11. 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.

  12. 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

  13. 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.

  14. 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.

  15. 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.

  16. 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

  17. Jennifer Flake

    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?

  18. 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

    1. 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?

      1. 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

    2. 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

  19. 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?

    1. 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.

      1. 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?

      2. 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.

  20. 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!

  21. 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.

    1. 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.

    2. 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.

  22. 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 🙂

  23. 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!

  24. Nicole Esquivel

    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

      1. 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

          1. 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!

          2. 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

  25. 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?

  26. Charlotte M. Buckles

    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

  27. 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?

    1. 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

  28. 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

  29. 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?

  30. 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

    1. 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.

      1. 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?

  31. Jennifer Flake

    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?

  32. 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

  33. 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.

  34. 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?

    1. 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.

  35. 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?

    1. 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?

  36. 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!

  37. 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.

  38. 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?

    1. 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.

  39. Rochelle McKenzie

    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?

    1. 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.

  40. 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!

    1. 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.

  41. 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!

    1. 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.

  42. 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.

    1. 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.

      1. 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

  43. Loretta McLaughlin

    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.

    1. 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.

    2. 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..

    1. 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

  44. 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,

  45. 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?

    1. 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.

      1. 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

  46. 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

  47. Rochelle McKenzie

    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.

    1. 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.

  48. 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.

    1. 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

      1. 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?

  49. 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.

  50. 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

    1. 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

  51. Randall Huling, M.D.

    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?

      1. 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??

        1. 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.

          1. 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!

          2. 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.

          3. 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.

  52. 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??

    1. 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

  53. KATELYNN GRIFFITH

    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 ?

  54. 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?

          1. 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?

  55. 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??? ????

    1. 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.

    2. 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.

  56. 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.

  57. 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.

    1. 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.

        1. 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.

    2. 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

      1. 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.

    3. Holly Massey, CFPC

      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.

  58. 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

    1. 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.

      1. 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!

      2. 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.

  59. 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.)

  60. 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?

    1. 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.

      1. 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

    1. 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.

      1. 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.

  61. 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!!!!

    1. 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.”

    2. 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.”

  62. 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?

    1. NAVEEN MAJETY

      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.

      1. 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.

    2. 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.

      1. Charlotte M. Buckles

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

  63. 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!

    1. 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?

  64. 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

  65. 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?

    1. 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.

  66. Courtney Sims

    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.

    1. NAVEEN MAJETY

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

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

  68. 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

  69. 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?

    1. Manny Oliverez

      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.

  70. 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?

    1. Holly Massey, CFPC

      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.

  71. 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?

    1. Manny Oliverez

      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.

      1. 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.

  72. 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

    1. 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.”

  73. 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

  74. 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

    1. 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

  75. 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

  76. 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.

    1. NAVEEN MAJETY

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

  77. 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.

  78. 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,

    1. 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

  79. Nataliya Taneva

    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!

  80. Muhammad Imran

    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.

    1. NAVEEN MAJETY

      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.

      1. Muhammad Imran

        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.

        1. Muhammad Imran

          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.

    2. NAVEEN MAJETY

      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.

      1. Muhammad Imran

        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.

  81. 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

    1. LEONA GUILLORY

      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.

      1. 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.

  82. 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?

    1. 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?

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

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

    1. 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.

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

  86. 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 !!

    1. 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.

  87. 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 ?

      1. 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.

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

    1. 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.

  89. 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.

    1. NAVEEN MAJETY

      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.

  90. Scot Wilfong D.O.

    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.

  91. 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.

    1. NAVEEN MAJETY

      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.

  92. NAVEEN MAJETY

    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?

  93. 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.

    1. NAVEEN MAJETY

      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 !

  94. 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

  95. 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

    1. NAVEEN MAJETY

      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.

  96. 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

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

  98. 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?

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

  100. 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?

    1. 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.

  101. 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?

  102. 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

  103. 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.

    1. 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.

  104. 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?

    1. 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.

      1. 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?

  105. 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

  106. 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

  107. 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.

    1. 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.

  108. 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

  109. 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?

    1. 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.

  110. 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.

      1. 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

    1. 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.

    1. 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.

      1. 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.

  111. 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!

    1. 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.

  112. 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

    1. 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.

    2. 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!

    3. 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.

      1. 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.

  113. 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?

    1. 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.

    2. 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!

  114. 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?

      1. 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.

  115. 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?

    1. 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.

  116. 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?

    1. 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

      1. 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?

        1. 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.

    1. 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.

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

  117. 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.

    1. 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.

  118. 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?

    1. 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

  119. 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???

    1. 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

  120. 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.

    1. 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.

  121. Pingback: Top 5 Resources for Billing Medicare Annual Wellness Visits

  122. Dr edgar hoffman

    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

          1. 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.

          2. 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.

  123. 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

  124. 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.

  125. 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?

  126. 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!!

  127. 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.

  128. 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?

    1. 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.

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

  130. 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?

    1. 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?

      1. 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

        1. 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?

  131. 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.

    1. 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

      1. 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.

  132. 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?

    1. 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

  133. 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

    1. 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