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Q&A: Am I Just Dealing with a Coding Department that is Ignorant?

Health Insurance Companies Process 1 in 5 Claims Wrong

Am I Just Dealing with a Medical Billing Department that is Ignorant? Medicare Patient Wonders if 99397 was Coded Correctly

I received the following comment and questions from one of my readers, Mark. He is a Medicare patient who had a full routine physical exam from his physician. Mark asks if his doctor coded the physical properly with a 99397, which is not covered by Medicare, or if the doctor should have used the Annual Wellness Visit code, G0438 (or G0439), which is covered by Medicare.

There is a lot of confusion out there on what these exams are comprised of and how these exams should be billed. We come across this type of question often, so I thought I would share it in this blog post.

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

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

I did a little research and discovered the following on the Medicare.gov web site under “Welcome to Medicare Preventative Visit” where it discusses “Your costs in Original Medicare”: “You pay nothing for the yearly ‘wellness’ visit if the doctor or other health care provider accepts assignment. If you get additional tests or services during the same visit that aren’t covered under these preventative benefits, you may have to pay coinsurance, and the Part B deductible may apply.”

What is there in either a G0438 or G0439 exam that is not covered in a 99397 exam; and, why wouldn’t I just be billed for whatever a 99397 exam covers that is above and beyond the scope of a G0438 or G0439 exam? Am I being defrauded by my medical service provider, or am I just dealing with a coding department that is merely ignorant?” 

A: There is no fraud or ignorance here but there was a failure in communication from the doctor’s office. A full physical exam, 99397, is different than an Annual Wellness Visit, G0438/G0439, or “Welcome to Medicare Exam”, G0402. A full physical is NOT covered by Medicare and patients are responsible for the cost and can be billed. Some secondary insurance companies may cover the full physical exam, which helps beneficiaries.

The decision for which service a patient should receive needs to be made prior to any exam as it determines the scope of the exam and the documentation needed for the exam. Plus, if explained properly to the patient, the patient can choose which exam they want the physician to perform. The patient may still have to pay based on their decision, but at least there are no surprises.

Unfortunately, there is a lot of confusion as to what each exam covers and how it is reimbursed by Medicare (from patients and from physician’s offices). Medicare does not make things easy.

There are 3 exams that cause the confusion:

    • Comprehensive Preventative Medicine: 99387 New Patient / 99397 Established Patient
    • Initial Preventative Physical Exam (IPPE) aka “Welcome to Medicare Exam”: G0402
    • Annual Wellness Visit (AWV): G0438 Initial / G0439 Subsequent

Let’s take a closer look at what each procedure code covers and how it could have been billed in this case.

Initial Preventive Physical Exam (IPPE) G0402

Medicare Patient at Annual Wellness Exam AWV G0438 G0439

The Initial Preventive Physical Exam (IPPE) G0402 could have been provided and billed out by your provider during the first 12 months of receiving Medicare. If you saw the physician before 11/16/2011, this Medicare exam would have been covered.

There were also additional once-in-a-lifetime benefits that could also have been provided to you in conjunction with the IPPE (a “Welcome to Medicare” EKG, the Ultrasound Screening for Abdominal Aortic Aneurysm (AAA), and the Pneumococcal Vaccine).

However, if you were not seen by a provider or if your physician did not actually provide these services, then, unfortunately, you missed out on these benefits, as they must be done within the first year of Medicare eligibility. It is the patient’s responsibility to schedule this exam, however, I suggest that it is good customer service for the medical office to call the patient to schedule an appointment.

The components of an IPPE are:

    • Review of the beneficiary’s medical and social history
    • Review of the beneficiary’s potential risk factors for depression and other mood disorders
    • Review of the beneficiary’s functional ability and level of safety
    • An examination
    • End-of-life planning
    • Education, counseling, and referral based on the previous five components
    • Education, counseling, and referral for other preventive services

Medicare provides a quick reference information sheet on the IPPE at http://www.cms.gov/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf

Annual Wellness Visits (AWV) G0438 / G0439

The AWV is not an annual routine preventative physical exam. Those exams are much more comprehensive than the AWV. Many healthcare providers believe that the AWV is a routine physical exam and bill the G0438/G0439. That is incorrect.

In this case, it looks like the physician knew the differences in the exams and their requirements and limitation, and recommended a full physical, which was agreed to, so an AWV would not be appropriate to bill.

It sounds like the cost may have not been explained. It is technically not the responsibility of the medical practice to explain the cost of the full physical exams, as it is a Medicare non-covered service by statute, but it sure would be a good idea to provide the patient with the cost information first, instead of letting them find out later that they owe money (and usually a substantial amount).

The Annual Wellness Visit is comprised of only the following elements:

    • 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

Also, since the routine preventive exam (99397/99387) is different than the AWV, Medicare allows both services to be performed at the same visit and billed with proper documentation.

A complete list of the covered services of the AWV can be found at this link: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads//MM7079.pdf

Comprehensive Preventative Medicine:
99387 New Patient / 99397 Established Patient

Lastly, we come to the Comprehensive Preventative Medicine Exam. Patients and medical providers refer to this exam by such names as a routine physical, annual physical, annual exam, well exam, routine exam, full physical, annual routine physical, etc.

Regardless of what the exam is called, the CPT codes 99397 (established patient) and 99387 (new patient), which represent the preventive care examination, have very specific parameters and are never reimbursed by Medicare.

The 99397 is defined as the following:

Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older.

Just as an example, according to the United Healthcare website for patients with a Medicare Advantage Plan (link at: https://www.uhcwest.com/vgn/images/portal/cit_60701/600758632_Medicare_Advantage_$0_Copay_Wellness_Exams-2012_Coding_Procedures.pdf), an Annual Routine Physical is defined as the following:

The purpose of the Annual Routine Physical is to provide a comprehensive physical examination in order to screen for disease, promote a healthy lifestyle, and assess an individual’s potential risk factors for future medical problems. Any clinical laboratory tests or other diagnostic services performed at the time of the wellness visit may be subject to a copayment or coinsurance as applicable.

This exam includes all or some of the following components as applicable:

    • History
    • Vital Signs
    • General Appearance
    • Heart Exam
    • Lung Exam
    • Head and Neck Exam
    • Abdominal Exam
    • Neurological Exam
    • Dermatological Exam
    • Extremities Exam
    • Male Physical Exam: Testicular, Hernia, Penis, and Prostate Exams
    • Female Physical Exam: Breast and Pelvic Exams
    • Counseling to include healthy behaviors and screening services

Summary

The Annual Wellness Visit G0438 and the 99397 are completely separate codes and the AWV is not to be used in place of the 99397. Since the 99397 is never covered by Medicare, and the patient accepted the physician’s recommendation of a full physical prior to any exam being performed, with just the provided information, everything looks like it was done properly. Sometimes a secondary insurer will pay for these services, but it depends on your individual coverage and benefits.

Additionally, billing the 99397 (not covered by Medicare) and billing the AWV at the same time is not fraudulent and can be billed if that is exactly what happened and the physician has the proper documentation.

Please note that Medicare rules are complex and change all the time. What is current information today may be incorrect tomorrow. Always check with your local Medicare carrier.

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is a 20 year veteran of healthcare having managed medical practices. He advises medical practices, physicians and practice administrators on how to run their practice and manage their medical billing and revenue cycle management. Manny speaks, blogs and makes videos at www.CaptureBilling.com, a blog that is tops in the medical billing and coding field. READ MORE

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27 Responses to Q&A: Am I Just Dealing with a Coding Department that is Ignorant?

  1. Manny. The annual wellness visit can be challenging to implement into practice. Often, I hear of primary care practices avoiding the visit, because they do not have a “protocol” to navigate the visit with, and they also do not know who should be doing the visit. Of course the physician can perform the visit, but is this the best use of the physician’s time since it is a more time consuming visit? In your experience, who would you recommend perform the visit? Since the requirements of the visit could be performed by a Registered Nurse, do you ever see practices doing this? If the patient is in for a “sick” visit, the RN could do the annual wellness visit first, and then the provider could see the patient. Not only would the patient’s medical information be up to date and screenings would have already been performed, but the physician could also do his/her assessment and take less time. What are your thoughts on this? I appreciate your time and insight.

    • Katie, yes the nurse can perform the AWV. It really all depends on management and how to use your resources. I believe the best time to do the Annual Wellness Visit is at the patient’s routine phyical. The nurse can do the AWV before the patient sees the doctor for the Exam. Now the doctor has a complete picture, the physical exam and the AWV, to come up with the plan of care for the patient.

      • Thank you for the response. What if the patient will not be seeing the physician (or PA or NP) that day? Can the nurse provide the visit completely separate? How would that work? Thank you.

  2. For the Medicare Advantage plan example when 99387 is allowed and being paid – (Understood that 99387 is medicare non covered and is exception since in this case advantage plan pays it). In this scenario when 99387 is payable can the hospital and the physician both bill separately (and get paid) for 99387? Example is Flu or pneumonia Vaccine done at hospital clinic being billed as Vaccine + Admin Code + 99387 as well as Physician billing separate solely for 99387. If this is allowed, are there any E/M codes generally not separately payable to both OP Facility and Physician? Upon reading the advantage policy it seems specific to the physician 99387 payment so unclear if payment should be allowed for a hospital payment on 99387.

    • Raven I am not sure why the hospital would do a full routine preventative exam just to give the patient a vaccine. And if they did then the physician should not be giving the patient another full routine exam.

  3. My mother is 79 years old and deaf and has limited vision. She is sometimes mildly confused. She made an apt with her family practice doctor after weeks of not being able to sleep. She told him “I think there is a physical reason why I can’t sleep.” She also has heart block and prediabetes.

    The doctor did a physical exam which happened to be the SECOND ONE for that year so it was not covered by medicare and united health care.

    The doctor’s bill for a flu shot, a pneumonia booster shot and a urine analysis was $659. No ekg or chest xray.

    He gave her a prescription for pills to help her sleep. He ordered many labs.

    The labs were not covered , the bill is huge, she has no money . She has to see a nephrologist every year and the labs for the kidney doctor can’t be done because the lab won’t do them until the bill for the second physical labs are paid.

    So the family practice doctor efficiently cut her off from future medical care.

    How can a physician charge for more than one physical exam in a year for a person like my mother? Doesn’t their office software notify the biller that this is a duplicate exam?

    All she wanted was to get her blood sugar checked and be able to sleep, which she did get but it wasn’t accepted by the insurance company.

    • We come across this a lot where the practice does not know how to bill properly.

      Based on what you wrote it sounds like the appointment was for a problem-oriented visit which should be covered by Medicare. The flu shot should have been covered as I believe the pneumonia vaccine. Since this was a “sick visit” I would have thought the urinalysis would have a sick diagnosis attached to it which should have paid along with other tests that would have been ordered for the condition. This may be a case where the diagnosis was incorrect causing denial of payment.

      Keep in mind that routine preventative physical exams are never covered by Medicare. So technically they can bill it multiple times but who would?

      Now if they have paper charts they may have just missed the first physical. If they have software, the software must be setup properly to indicate to the office that an exam was previously done.

      I am just guessing here because without reviewing the documentation for billing I really don’t know and am guessing at possible scenarios.

  4. I just paid $257 for my wife’s annual physical exam!
    My primary is Medicare, and my secondary is Hartford (WEB/TPA).
    I tried to get her physical recoded as “AWV” with NO success.
    Why does Medicare not cover Physicals?

    • Robert the AWV visit and a routine physical exam are two completely different services. You doctor could not change the coding becasue that would be fraudulent billing just to get paid. Medicare does not like that.

      Yeah Medicare has never covered routine physical. They hardly cover anything routine, only problem oriented visits and procedure and even then only the ones Medicare deems medicall necessary.

      As to why Medicare does not cover physicals when the government requires all commercial insurance carriers to cover physicals is a mystery to me. I am sure it has to do with costs.

      Next time you go in to see the doctor make sure they tell you what they are doing, an Annual Wellness Visit or a Routine Physical Exam, so you can be informed before the service is performed. After it’s done, as you know, is too late.

  5. Thanks for your guidance. I had a physical based on your distinction between it and an AWV…lab tests were done (and thankfully paid for) which seems to be one clear distinction between the two. Unfortunately when I had the physical, recommended by the Doctor because it had been “over a year since I had one”, I wasn’t aware of the alternative visit types available to me. I was billed for the 99397 physical. Now, thanks to you, I know.
    However, I’m still a little confused regarding the billing issue. In your example Mark says “I was informed that because I had received a 99397 physical they couldn’t bill Medicare for a Wellness Exam and then bill Tricare4Life and me for the additional services over and above the Wellness Exam, as that would be considered fraudulent.”

    You say a few things…I can’t tell if they are specifically in response to that statement…in your Summary:
    “Sometimes a secondary insurer will pay for these services, but it depends on your individual coverage and benefits.”
    “Additionally, billing the 99397 (not covered by Medicare) and billing the AWV at the same time is not fraudulent and can be billed if that is exactly what happened and the physician has the proper documentation.”

    I had trouble following that. What do you mean by “if that is exactly what happened”?

    Finally, IF my provider had forwarded the charge to my supplementary plan for payment and it was rejected, would that charge appear on my statement of benefits from AARP as a rejected charge or would it simply not appear? In other words, if it does not appear can I conclude that it was not submitted?

    At this point paying the full charge is by far the easiest thing to do. I just can’t tell whether it’s the correct thing to do.

    Thanks again….

    • Hi Bob —

      In your comment Bob you stated that you were still a little confused which is very common when dealing with Medicare. Trust me, you are not alone feeling that way.

      When I say “if that is what happened?” it is essentially my disclaimer. In answering your question I have no access to the doctors documentation, what else was coded at the visit, the diagnosis codes and the EOBs. There are too may variables so I have to make some assumptions based only on the information presented.

      Yes if the charge was forwarded to your supplementary plan, even if it was rejected, you should have been notified. I would call your supplemental plan to confirm they did not receive the charge and then call your doctor to have the claim submitted to them.

      Of course the supplemental plan may or may not pay. If they pay Hooray!! If not, pay the doc.

      Hope this is clear. –Manny

  6. I’m pulling my hair out and I’m starting to wonder if I’m wrong. In December I went in to the doctor for an annual exam which turned into a confirmation of pregnancy visit. They’ve billed me for the visit, I get it, that’s fine. But at this same visit they sent me for lab work. They did several different tests all of which were considered preventative except two. They charged me for an HIV screening and an RBC antibody screening. So, I did my research, I went and read about preventive services for pregnant women on healthcare.gov, US Department of Health and Human Services, Affordable Care Act, and the United States Preventive Services Task Force. All of these websites and manuals and various things I read said HIV screenings and RBC antibody (or RH blood typing and antibody testing) are preventive services for pregnant women.

    I talked to my insurance, they said it needs to be billed as preventative, I talked to the billing office, who sent it to the coders, who said those aren’t preventative because the doctors notes didn’t say so. I talked to the doctors office who said that it was a confirmation of pregnancy visit and they don’t deal with lab services. No one knows anything about preventative services, and they won’t give me to anyone who does. Are these not preventive? Is there someone at the billing department who should know??

    Please help me.

  7. I just received a bill for $300 for my Annual Wellness Visit GO438 after it was denied by Medicare. I only scheduled this longer visit as the physician told me Medicare covers it 100% since I have not had one and I got Medicare in 2002. I looked at my primary insurance and do not see any submissions beyond the blood work I had done that same day which were covered, but no office visit.

    Medicare is my secondary payer (and I repeatedly remind them of the fact) as my spouse has health insurance on both of us through his employment. So all I can assume is that I have to pay the full amount because I have two health insurance plans.

    Three hundred dollars is nearly 50% of my monthly net disability benefits of which I need to pay for medications and other non-covered services and co-pays for my other five doctors. I don’t know what I am going to have to go without for the next 4 months just to pay this to get the doctor off my back and charging overdue fees that accumulate monthly.

    I am bedridden so it is mighty difficult just to pick up a few more hours at work or find a part-time job!

    • Summer what I would of done if I were billing the claim is file it to the primary insurance which probably would of denied it since it is only a Medicare benefit. Now you may not see the G0438 from the primary insurance becasue it may reject the code outright and not even list it since it is a Medicare only code. Then I would then take that denial and forward a secondary claim to Medicare. Medicare should then pay.

      You may want to call the practice to submit the claim to Medicare if they have not already. My guess is that someone in billing didn’t know what to do and made it your responsibility.

      • Thank you for your response!

        I received my medicare statement today indicating why they denied the claim because they are secondary and primary was not billed at all. The practice will get a copy of this information. I am also changing primary care physician because I have never gotten them to bill correctly and I visit my doctors often because of three life threatening conditions. This practice is the only one that messes up billing every time. I guess they don’t understand and it’s not my job to train them in theirs.

        • Yup, sounds like they don’t know what they are doing. It’s a very common problem with medical practices not being able to bill properly. Usually it is becasue they just don’t have someone qualified to handle the billing.

  8. By request of Mayo Clinic (Jacksonville, FL) as our medical provider we both took the 2013 Annual Medical Examenation/99397 as mandatory for a comprehensive preventive evaluation with a basic cost per person $275.33. To our astonishment Medicare which policy considers the preventive annual screening as an important procedure for health of elderly citizens denied the payment and forced us to pay the bill from own pocket.

    After detailed itemization of tests included under both names (AWV – G0438/G0439 vs. Full Physical Exam – 99397) we revealed the same content, although 99397 is more essential for needs of prediction the current health conditions. Finally, the contradictory terminology between Medicare and Mayo Clinic affiliated to similar issues of preventive/screening diagnostic tests for elderly people is confusing, frustrated, stressed, and provides the magnet for payment’s trouble of retired community.

    After multiple attempts to resolve this issue between Medicare and Clinic we have applied for assistance to the Government Health Officials as well as to our Senator.

    Thank,
    Boris & Inna

  9. Dear Manny,

    Thank you for your quick response and advice!! I have spoken to the hospital billing department. They stated that they have sent an appeal to Medicare for coverage reconsideration, however, I do not believe that they corrected the coding before resubmitting the claim. The billing department is telling me that they are not able to view my mother’s account info while the account is in appeal status. Do accounts lock out if there is a pending appeal?
    I will continue to pursue the matter with the hospital billing department, as suggested. Thank you for your help!

    Sincerely,

    Naomi

    • A coverage reconsideration is a compete waste of time as routine care is by statue not a covered service. I can tell you now that the reconsideration request will not be approved. It can’t be by law. It all falls back to the documentation and coding.

      I have never heard such a thing as someone not able to view an account if it is in appeal status. I think they bad internal policies, just not willing to help much or don’t know how.

      I feel bad for you and your mom because the only way to get this corrected is to go through the billing department and they sound like they don’t know what thery are doing which is not uncommon in the medical billing field. I hope this gets resolved for you.

  10. Dear Manny Oliverez,

    I am having great difficulty with getting Medicare to cover my mother’s “Welcome to Medicare” exam completed during December 2012 and feel the physician’s office is also at fault for my mother being liable for approximately $1,600.00 worth of medical bills. My mother enrolled in the Medicare plan A & B in Sept. 2012. At that time, Medicare representatives encouraged my mother to make an appointment for the “Welcome to Medicare” Exam – a “complimentary” exam during the 1st year of enrollment in Medicare.

    After checking around for a physician that accepts Medicare assignments, I made an appointment for my mother, specifically requesting an appointment for the “Welcome to Medicare” Exam (I also obtained a physician signed letter stating that my mother was a new patient being examined for the Welcome to Medicare visit). However, the hospital coded my mother’s visit as a “Routine Physical for an Established Patient” instead of the G0402 visit.

    I wrote an appeal letter to Medicare (including the physician signed letter stating that the visit was for the Welcome to Medicare Exam) stating that my mother’s Dec 2012 visit was exclusively for the complimentary “Welcome to Medicare” exam. Now, we have received denial letters for all of the appealed claims.

    Any suggestions for helping to save my mother from having to pay more that $1,600.00 for what was suppose to be a “complimentary Welcome to Medicare Exam”? I did accompany my mother to her doctor’s visit, specifically stated why my mother made her appointment. Thank you for your time!

    Sincerely,

    Naomi

    • Naomi —

      Looks like you did all you could do before taking your mother to the doctor to try to ensure that the visit was covered. The problem here lies with either the way the doctor documented the visit causing the coder to have to code the service as a routine exam or the coder does not know how to code properly or a combination of both.

      I would focus my efforts on the doctors office as they are the ones that would have to work with Medicare if they did code the visit incorrectly to have it changed. Naomi you are correct that if done and coded properly a Welcome to Medicare exam should not result in any out of pocket expense to your mom. Talk to the doctor’s billing department.

      Manny

  11. My husband had a px last November. Since then he has changed jobs and we have a new employer and new insurance coverage. He had a yearly px again in June, 2012, just to verify good health. Now the Dr. office is saying they cannot bill for a px exam more than once per year, so we are responsible for the cost of the exam. Our current insurance would cover the exam 100% if it was billed as a px, which is what was performed. Can they really not bill for another px just because he had the px in Nov. 2011?

    • So Janet my first question is did the office bill the physical to your current insurance? They should have.

      A health insurance company can state that you can only have one physical in any 12 month period or one in the calendar year. Two different time periods. What coverage time limitations you have will depend on your individual insurance policy. Yes you may be responsible for the exam but the office really does not know that unless they were to call the insurance company and not only verify your benefits but also see if you had a recent physical. This is something most primary care offices do not do. Sounds like the staff only told you that your exam would not be covered based on general information and what usually is the case. But every policy is different. In your particular case since you changed jobs and insurance companies, I would be surprised if your carrier did not pay for your husband’s physical if you have coverage.

      Even if you already have paid the office for the exam I would insist that they bill the insurance company. Let me know what happens. I am sure other people reading this blog or doing internet searches would like to know also as I am sure your situation is not unique. It may help someone. -Manny

  12. Thank you for the reply, but I'm afraid you missed the most important aspect of my query. That is, I did a little research and discovered the following on the Medicare.gov web site under “Welcome to Medicare Preventative Visit” where it discusses “Your costs in Original Medicare”: “You pay nothing for the yearly ‘wellness’ visit if the doctor or other health care provider accepts assignment. If you get additional tests or services during the same visit that aren’t covered under these preventative benefits, you may have to pay coinsurance, and the Part B deductible may apply.” What is there in either a G0438 or G0439 exam that is not covered in a 99397 exam; and, why wouldn’t I just be billed for whatever a 99397 exam covers that is above and beyond the scope of a G0438 or G0439 exam? Furthermore, as the November 2011 visit was on the 15th, one day before my 66 birthday, shouldn't I have received the IPPE G0402?

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