Medicare and Newborns Codes cause some Confusion for Medical Practices
I received the following questions from Jean so I thought I would answer them here on the medical billing and coding blog in case anyone else could use the information.
Q: What is the CPT code for an annual exam for Medicare ….and what are the CPT codes for newborns for the first day, second day, and discharge day …?
A: The CPT code for the annual routine physical exam for Medicare is 99387 (preventative medicine E/M new patient age 65 and older) or 99397 (preventative medicine E/M established patient age 65 or older). This is the same code for all insurance companies. Remember that Medicare does not pay for these codes. You are able to collect the fees for these services from the patient. An Advance Beneficiary Notice (ABN) is not needed since this is a Medicare non-covered service.
If you are asking about the Annual Wellness Visit then the codes are G0438 and G0439. And don’t forget about the Welcome to Medicare exam, G0402.
Each of these codes is used for different reasons and have different requirements depending on what the patient needs or wants.
For more information check out my posts on the Welcome to Medicare visit using code G0402 for the Initial Preventative Physical Exam (IPPE), Annual Wellness Visit codes, and How to Bill a Well Woman Exam to Medicare using CPT codes 99387, 99397, G0101, Q0091, G0438 and G0439.
Now for the hospital, newborn codes look at the following:
99460 – Initial, Newborn
99462 – Subsequent, Newborn
99238 – Discharge <30 min
99463 – Initial and Discharge Same Day, Newborn
Make sure you look up all these codes in your codebook and use them appropriately and make sure your physicians document well.
My wife had an annual wellness visit to a family doctor, that didi not include the female-specific items covered by a Well Woman Exam. She had that done later by an Ob-gyn. The insurance won't pay for the Ob-gyn saying they already paid for a wellness exam.
What can she do? Does she need to get her family doctor to state that he didn't include those items in his exam? Should the Ob-gyn be using a different code?
This seems to be a common thing from what we gather from friends and neighbors.
Bob I may be able to shed some light but in order to do that I need the specific codes the doctor used to bill the service. The reason for this is that doctors and patients sometimes use different terminology that may not be the official terminology for a specific service. The billing codes are very specific and tell me exactly what was done. For example one doctor may say annual wellness visit and mean 99387 and another may mean code G0438 or G0439 or even G0403. A well woman exam could be 99397 or just Q0091 and G0101 and sometime the physician may use 99213 or 99214 (inappropriately). I threw out these codes just to show that the billing can be complex and some medical practices may not be completely up to speed on how to bill properly. I want to make sure we are talking about the same thing so I really need the codes billed. If your wife would not mind sharing the CPT codes and diagnosis codes that each doctor used I should be able to help. If they are not on your paperwork call the doctors' office billing department or billing company and they should be able to give you all the codes. Due to HIPAA regulations your wife may need to call. I'll be looking for your response. –Manny
If a patient has a Medicare Advantage insurance like Freedom Blue, can you do the g0438 for the anual wellness?
Scott
Hey Scott. Your question can be specific to each insurance company. In our own experience it can varies greatly. We are required by most Medicare Advantage plans to bill as we would to Medicare but we have come across a handful of these types of plans that do not want Medicare codes. Go figure. Unfortunately you will have to check with each of the specific insurance companies. Sorry but this is not a one size fits all issue. –Manny
I believe the Newborn hospital codes have been updated to
99460 initial
99462 subsequent
99238 discharge
99463 admit/dc same day
No I am confused. I mistakenly copied the deleted codes instead of the current newborn codes. Thank you for catching that. That is why I have a disclaimer 🙂
Thanks Again!
I'm confused…are Medicare newborn codes different than regular new born codes? I bill 99460-Initial, Newborn, 99462-Subsequent, Newborn, 99238-Discharge, and 99463-Initial and Discharge Same Day, Newborn. I don't see the codes you've listed even in the CPT book.