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Medicare G0438 – G0439: Two Annual Wellness Visit Codes

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Medicare Annual Wellness Visits AWV G0438 G0439Medicare Benefit: Annual Wellness Visits Covered

Good news for Medicare patients. Effective 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 come up with two HCPCS codes for these well 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 their subsequent AWV, G0439, one year after their initial visit. Remember that during the first year a patient has enrolled with Medicare the patient is eligible for the Welcome to Medicare visit or IPPE, Initial Preventative Physical Exam. This exam is billed using HCPCS code G0402. An Annual Wellness Visit code of G0438 should not be used and will be denied since 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 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

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 you local Medicare carrier’s website or contact them directly.

Are you billing for the Annual Wellness Visits at your practice? Let us know how its going and lee us a message below.

177 Responses to “Medicare G0438 – G0439: Two Annual Wellness Visit Codes”

  1. Chantal says:

    HI can you please help me with this scenario

    Patient is here for G0439 and vaccines Q2037 and 90714. I know I have to use G0008 admin code for the flu but what would I use the TD admin? 90471 or 90472?

    • Chantal this is the way I would code the scenario:

      G0439
      90714 with 90471
      Q2037 with G0008

      Medicare does not cover 90471, so unless the patient has a secondary insurance that will cover it, it may end up being patient responsibility.

      Hope this helps — Manny

  2. Louie says:

    Can we say that documentation requirements for preventive services 99391-99397 are the same as G0439?

    • Louie, the documentation for the AWV is totally different than for routine preventative services. If you do not have the proper documentation for the G0439 it is not billable.

  3. Sunny says:

    We are not getting paid for out Wellness G0438 codes, do we need a modifier?

    • Manny Oliverez says:

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

  4. Thelma Myers says:

    Can we legally bill a G0101 visit without the Q0091? Just want to know because there is confusion in our office whether or not we can bill the annual well woman gynecological exam without doing a pap smear on the patient and whether or not Medicare will pay the G0101 if we don’t include the Q0091. Please help and let me know where I can find documentation on CMS.GOV or another reputable site.

    • Thelma —

      You should have no problem billing a G0101 without a Q0091. You are billing G0101 because the provider performed, and documented, at least 7 of the 11 elements of a Pelvic and Clinic Breast Examination.

      The pap smear does not need to be be done if it is not medically necessary. But if you do the smear, then it is appropriate to bill Q0091. If you look at the code descriptions you will see what each code includes. We have billed G0101 to Medicare for our OBGYN/Family Practice clients with no problems.

      There should be more information on the topic at http://www.acog.org and http://www.aapc.com both of which should reference CMS.

  5. Maria says:

    Can you bill an office visit e/m code just for the V70.0 to Medicare? The problem I have is when we bill the preventive 99395 to Medicare it deny as non-covered, but the patient has Ohio Medicaid as secondary and will only pay the V70.0 if it is billed as an e/m office visit. most of the Medicaid secondary plans to pay for patient’s over age 20 for the annual visits. Could I use a modifier for Medicare to deny claim to bill to secondary for the 99214, 99215?

    • Hello Maria —

      No you cannot bill a problem orient office visit E/M code with V70.0, preventative care diagnosis, to Medicare. I am not familiar with the billing requirements for a physical with Ohio Medicaid and if they allow or want you to change the CPT code to a problem oriented E/M code. Just make sure you follow their guidelines to the letter.

      I do know some secondary commercial insurance companies do pay for the physical after Medicare denies it without changing anything. If the commercial secondary does not pay we would bill the patient the full amount since it was a non-covered service. There is not a modifier to use in this case.

      Sorry but I don’t think I am of much help to you in this case. –Manny

  6. Marisa says:

    Mr. Manny,
    I worked at primary care physicians, we billed Humana for Annual Wellness (G0438) and Office Visit Charge (99213/99214) and got paid last year and this year. Upon review, they retracted payment for G0438 for this year for denial reason that it is only paid once a year. reading your blogs/, now i understand that we should be using G0439 for subsequent Annuall Welness. If I corrected and resubmit the claims- could we get paid back for those dates/claims they’ve already retracted???

    • Marisa that is correct. G0438 is only ever billed 1 time. The first time you do an Initial AWV you bill G0438. At year 2 and every year thereafter that you bill the Subsequent AWV, G0439. G0438 is only ever billed 1 time. You should get paid for those once you submit a corrected claim if you don’t go beyond the timely filing limit. –Manny

  7. Ashish says:

    Hi Manny,
    Is there a documentation “Shortcut” for subsequent annual visits. For example, we have a unique 3 page form for our sAWV (HRA, sAWV, & Personalized Prevention Plan). Once done, next year there is often very little variation. Rather than rewrite all 3 pages, can we just update last year’s sAWV form and date it effective 11/14/2013? Would that suffice for an audit.

    • My understanding is that at the subsequent AWV G0439 you would just update the patient’s medical and family history, provider list, get new vital signs and weight, identify any cognitive impairment, update the screening schedule and risk factors list and provide advice. As far as what specific documentation would suffice for an audit, the more the better. I always encourage our doctors to document well especially with Medicare. I would make a new chart note referencing the initial AWV and documenting any updates. I would also initial, date and mark as reviewed the initial AWV visit, G0438, as a cross reference to the current visit. Check with your local Medicare carrier on their requirements.

  8. […] what questions they must ask and the documentation requirements in order to even be able to bill a G0438 or G0439. If there is an audit you may have to pay back thousands of dollars to […]

  9. Latha says:

    Manny,
    Can I perform annual physical 99397 during a subsequent visit, after AWV visit? Please clarify.

  10. Dr edgar hoffman says:

    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

  11. Christina says:

    I have a question, can you bill G0438 and 90732 G0009 together or is it bundled for Medicare?

    • Christina, yes you can bill for the Pneumococcal vaccine and the admin code with the Annual Wellness Visit. Make sure your provides document the AWV properly. Check with you local Medicare carrier for their billing requirements. Hope this helps. –Manny

      • Marcy says:

        Would you put a mod 59 on the 90715 vaccine in this scenerio?

        G0438
        99202-25
        90715
        90471

        • Marcy a modifier is not needed with the vaccine but if this is a Medicare patient I don’t think it will be covered. –Manny

          • Marcy says:

            Perfect! Thanks for getting back to me. Another thing, if they have a G0402, and a procedure of say, wart removal. Should you add a 25 to the G code? I wouldn’t think so because it is technically at HCPCS code, not a CPT code. What are your thoughts? Am I on the right track? I can’t find anything online.

          • Good questions Marcy. Typically we would add a 25 modifier to a problem orient visit that was coded with a G0402. For example:

            G0402
            99213-25

            In your wart removal example I would put a 59 modifier on the removal. Now that said, insurance companies and your local Medicare carrier may have their own rules on how they want something billed. Best to check directly with them to find out how they want it billed.

            I know, not much help but there is one set of rules for proper coding and another set of rules that each insurance has on how they want a claim coded for payment.

  12. 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

  13. Andres Velez says:

    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.

  14. Ilona says:

    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?

  15. Robin says:

    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!!

  16. Andres Velez says:

    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.

  17. [...] Medicare patient sees their physician for an Annual Wellness Visit. This generates a $100 service payable by Medicare. Medicare usually pays 80% of the $100, or in [...]

  18. Rose says:

    Our office was told b/c we are OB/GYN we don’t meet the qualifications to bill out G0438/G0439? Our docs have always done preventative and routine exams can you clarify?

    • Rose —

      Not sure who told you that OBGYN physicians could not bill for an Annual Wellness Visit but here is some info from Medicare.

      MLN Matters® Number: MM7079 Revised
      Related Change Request (CR) #: 7079
      Related CR Release Date: February 15, 2011
      Effective Date: January 1, 2011
      Related CR Transmittal #: R138BP and R2159CP
      Implementation Date: April 4, 2011

      Who is Eligible to Provide the AWV with PPPS?
      • A physician who is a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Social Security Act (the Act); or,
      • A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act); or,
      • A medical professional (including a health educator, registered dietitian, or nutrition professional or other licensed practitioner) or a team of such medical professionals, working under the direct supervision (as defined in CFR 410.32(b)(3)(ii)) of a physician as defined in the first bullet point of this section.

      Do some more research by contacting your local Medicare carrier.

  19. Margo Narvaez says:

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

  20. Sue says:

    Getting G0439 denials this year with V70.0. Tried to be creative :)
    looks like sticking to 99213 or 99214 is wise this year. Do you jave the same issue? How did you go past it?

    • Sue I just talked to some of the team and they said they are not having any problems with getting G0439 paid. Looks like you have something odd going on there.

      We have had success billing G0439 with an Annual Routine Physical, 99397, with the occasional 99212 thrown in for a problem and got paid for all three on the same date of service.

      I would be careful with billing a 99213/99214 as a AWV as those codes are for problem oriented visits.

      What was the actual denial you got from Medicare?

      • Andres Velez says:

        How did you get paid for the 99397 from Medicare they dont accept those codes? If g0439 is only to be billed to Medicare then 99397 should not have been paid in that Date of service? Thank you

        • You are correct Andres that Medicare does not pay for a 99397 Annual Preventative Medicine Exam (or routine exam). But you can make the patient pay for the 99397. You don’t even need an ABN but I would recommend using one just to let the patient know they are responsible financially prior to the service.

          Remember a G0439 is NOT a routine exam. If you do a routine exam then you should bill 99397.

          An AWV is a wellness visit. The patient and doctor goes a series of required elements as listed below:

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

          Note that there is no mention of a physical exam because the AWV is not a routine exam as those are not covered by Medicare.

          Medicare allows you to bill for both a annual preventative medicine exam and the G0438 or G0439.

          If the patient is sick on the date of service you can even bill an E/M code for that service. The codes billed may look like this:

          99397
          G0439
          99212-25

          Does this help?

  21. Debra Davis says:

    Is there a good way to explain to our Medicare patients why they get billed for the well woman exam ($80.00). They keep saying that they are calling Medicare who is telling them that our billing dept. should call them because we are coding it wrong (99397) and we need to change our code. They sign the ABN form when they come in and it states that the $80.00 is a non-covered charge and they will be liable but they are still not getting it. What would you advise I say to them.

    • Debra —
      There may be some confusion in terminology by your patients. A Well Woman Exam (also known as a Breast and Pelvic Exam) G0101 and Pap Smear Collection Q0091 are covered services from Medicare. A Routine Preventative Medicine Exam 99397/99387 (Some call it an Annual Physical) is not covered by Medicare and does not even need an ABN.

      Download our Billing Well Woman Exams to Medicare report. It will explain in detail how to bill for this exam and I believe it will give you information so you can come up with a script and possibly even a handout to explain to your patients how Medicare and the patient will be billed. The carve-outs tend to be tricky to patients.

      CLICK LINK TO GET REPORT: http://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

  22. Tyeisha says:

    I’m new to billing and I’ve been trying to get paid for the G0403 with the G0438. They will pay with the g0438 with dx V70.0, but they won’t pay for the g0403 with dx v70.0. So I refiled the G0403 with a medically necessary dx 414.01 and they still denied it. Help, am I doing something incorrectly?

    • Tyeisha, a routine EKG is a once in a lifetime service that must be furnished with the Welcome to Medicare Visit G0402 and cannot be done more than 12 months after the effective date of the patient’s enrollment into Medicare Part B. You will not get paid in the scenario you described above because a routine EKG is not a covered service. Basically you performed a free service and it needs to be written off per your Medicare remit. Sorry.

      Medicare only pays on EKGs if they are medically necessary with the appropriate problem oriented diagnosis code.

      So you cannot do routine EKGs on Medicare patients per the government. –Manny

  23. Saifee says:

    Hi
    Can we bill G0438 for non medicare patient like for UHC patient. Also does this service specific patient’s age. Please let me know

    Thanks

    • Saifee G0438 can only be utilized for billing Medicare patients, who are typically 65 years and older. The Annual Wellness Visit G codes cannot be used for commercial insurance.

      Please keep in mind that when billing G0438, there are key components which are required in order to be properly reimbursed by Medicare and are as follows:

      • Taking the patient’s history
      • Compiling a list of the patient’s current providers
      • Taking the patient’s vital signs, including height and weight
      • Reviewing the patient’s risk factor for depression
      • Identifying any cognitive impairment
      • Reviewing the patient’s functional ability and level of safety
      • Setting up a written patient screening schedule
      • Compiling a list of risk factors
      • Furnishing personalized health services and referrals, as needed

      Subsequent annual wellness visits, G0439, require that all the components above be updated and the doctor must also provide health advice to the patient as needed.

      Also remember that an AWV is not a Routine Physical Exam which can also be performed and billed to the patient.

      Let me know if this helps –Manny

  24. Robin says:

    Thank you so much for sharing so much information on this complicated subject! As of today, we are receiving numerous take backs from Medicare for our Annual Wellness visits because the patient either had lab tests, xrays, or and EKG on the same day. They all were paid by Medicare at the time they were submitted, however, now they are taking back their monies on the AWV. I read the MLN CR 8153 and they stated they are taking back their money. I am not sure why they would on these types of visits? Has anyone else had this happen lately?

    Thank you!

  25. Mary Smith says:

    We have been billing a lot of the Annual Wellness visits G0438 and G0439 (dx: V70.0). We have also been doing an Evalualtion & Mgmt code 99213 with diagnostic codes with either of these visits, using a modifier 25 on the E& M code. But we have had deniels on the Depression Screening (G0444, dx: V70.0). We have tried it without a modifier and have resubmitted with 59 modifier on this code, also denied. Any suggestions for payment of the Depression Screening?

  26. Alex says:

    Is G0438/9 billable with pos 12?

    • Alex if you look at MLN Matters Number MM7079 there are specific guidelines to billing for a specific place of service (POS) but there looks like there is no exclusion as to where the Annual Wellness Visit may be performed. I did find one reference from the University of Washington Physicians that actually gave the following POS codes that should be fine: 11, 12, 13, 22, 23, 71, 77, or 85.

      Check with your local Medicare carrier for their billing requirements –Manny

  27. Anand says:

    Medicare HMO “SUMMA” is denying G0438 code & asking us to use equivalent code. What could be an equivalent code ?

    • WHAT? Equivalent code?

      Could Medicare mean G0439? Maybe.
      Could Medicare mean G0402? Maybe.
      Could Medicare just be crazy? Probably.

      I ask some of our billers if they have ever had a denial like yours Anand and no one had.

      Sounds like Redetermination time. Let me know if you find out more information on the denial. –Manny

  28. Colette says:

    We had a patient come in for the AWV, the patient also has hypertension and needed refills on meds, so an office visit was also billed at that time with a modifier 25. The physician also did an ear irrigation at that visit, code 69210. We were paid for each of the lines but now the medicare replacement insurance is trying to recover the amount paid on the well visit stating that it should not have been paid within the global period for CPT 69210. Should we have attached a modifier to the G0439 code?

  29. Michael Rosen says:

    Alot of problems with medicare. Numerous claims being denied. When you call medicare you get put on hold and shuffled around. No one can seem to be able to answer any questions.

  30. David Wilson says:

    I come across this blog on most searches I do on the AWV. I appreciate that you were on top of providing billing information and advice to physicians so quickly after the AWV became an option for physicians.

    • Thank you David. We are still educating doctors. Most providers I come across believe that a AWV is a full routine physical. I have another presentation next week with a large Family Practice to help train the physicians on the differences in the two services and how to document the AWV properly. I think i need to write a more detailed post. Thanks again –Manny

  31. Elizabeth says:

    My Dr billed me for a office/outpatient visit on the same day as my wellness visit
    (which they coded wrong I found seen seeing your website)
    are they allowed to do this?

    • Elizabeth, yes a provider can bill both an office visit and an AWV on the same day. They are two separate services with different documentation requirements. Medicare should pay for both services if billed properly. –Manny

  32. pat chang says:

    Will Medicare pay for G0439 and 99213 in one office visit?

    • Medicare should pay for both codes since they are different services. Make sure you have separate documentation for each service. Check with your local Medicare carrier for their billing requirements and the type of documentation needed especially for the G0439 Subsequent Annual Wellness Visit.

      Thanks for your question Pam –Manny

  33. K Dodd says:

    By 12 months between the visits does it HAVE to be exactly 365 days or can they be seen for subsequent wellness visits if it’s within a week of their previous visit? How strict is the whole 12 month thing? We have just a few of our patient who have been scheduled for subsequent visits just shy of the 365 day mark. For routine annuals this was never a problem…

    • Kamara it has been our experience that if they say one year and you send in a claim that is only 364 day from the last visit that it will be denied. If it was my practice I think I would reschedule those patients for the following week to make sure the claim is not denied due to time limits.
      You are correct that for the routine annuals this was never a problem because those physicals (99387/99397) were and are still not covered by Medicare. So a patient could have two or more a year because it is a non-covered service that the patient is by statute responsible for.
      Remember if you are performing a Routine Annual Physical and an Annual Wellness Visit you are able to bill for both since they are two different services.

  34. Elizabeth says:

    Manny can OB/GYN practice use the G0438 and G0439 codes?

    • Elizabeth take a look at MLN Matters Number MM7079. This Medicare publication tells you the Providers that are eligible to perform a G0438 and G0439. Below is an excerpt from that publication. Looks like OBGYNs are OK.

      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.

      — Manny

      • R Rodriguez says:

        The provider must be the Primary Care Physician though or else someone isnt' getting paid and claims will be duplicated or more between various offices.
        If a patient has a PCP and sees the OB/GYN for the bi-annual Pap then they should not be coding for the AWV. These should be done by the PCP and not the specialist.
        We are having to appeal a situation right now and the specialist office coded for the AWV last year. We did not know coded for their AWV-initial and our visit is being denied. Medicare specifically asked the patient who was PCP and did the specialist go through certain questions. PCP did but specialist only saw them for the specialty issue.

  35. Pauline says:

    We will be doing an annual routine physical exam for this patient and the coding that we are planning on using is 99335-25 G0439 for the cpt we have dx code V70.0 for the g0439 and 472.0, 401.9, 438.85 for the 99335

    • You would need to bill the appropriate Annual Routine Physical Exam that you are doing with the appropriate code such as 99397 with a V70.0. You did not say you were doing an Annual Wellness Visit so you should not be using G0439. If you are also doing an Annual Wellness Visit (Subsequent) in addition to the Annual Routine Physical Exam you can bill for both. The applicable diagnoses for 99335 should really be the medically necessary diagnoses – not the V70.0 since 99335 is for a problem oriented visit in a rest home.

      Based on only the information provided, and if you are also performing an AWV, I think this is what you may want to look at billing to Blue Cross and then to the Medicare Secondary:

      99397 V70.0
      99335-25 472.0, 401.9, 438.85
      G0439 V70.0

      Please be sure that the documentation requirements are met for all services provided and check the coding guidelines of the carriers. Also remember that Medicare does not cover Annual Routine Physical Exams so if BCBS holds the patient responsible for a copay or co-insurance, bill the patient. — Manny

  36. Pauline says:

    Manny if a patient has BC/BS as primary and Medicare as secondary could we possibly bill out the G0438/G0439 code?

  37. Mirna says:

    Hi Manny,

    Please help me identify the following cpt coding for: 1) DepoMedrol 20mg 2) DepoMedro 40mg 3) DepoMrol 80mg. 4) Does the injection code 90471 apply?

    Thanks,
    Mirna

    • The codes for Depo-Medrol (methylprednisolone acetate) can be found in the current edition of the HCPCS Level II coding book. Look at Appendix 1 – Table of Drug and Biologicals to find Depo-Medrol in the alphabetical listings. There you will find the drug name, unit, route and J code. Once you have the J code find the description in the Drugs Administered Other Than Oral Method section of the coding book. Make sure that the description matches what you are giving the patient.

      J1020 Depo-Medrol 20 mg
      J1030 Depo-Medrol 40 mg
      J1040 Depo-Medrol 80 mg

      CPT code 90471, immunization administration, does not apply in this case because Depo-Medrol is not a vaccine. A better code to use would be 96372 , Therapeutic, prophylactic, or diagnostic injection, subcutaneous(SQ) or intramuscular(IM).

      Hope this helps. –Manny

  38. SHull says:

    We have a situation where we are trying to figure out how to bill a NP to our office, but not new to Medicare. The PT has already had their welcome to Medicare exam G0402. We are trying to decide if we should bill with G0438 or G0439. Logically, I believe we should bill with the subsequent. But with this PT being new to the office, that is where I am getting thrown off my train of thought. Please help.

    • An Annual Wellness Visit is not subsequent to the G0402, Welcome to Medicare exam. Billing a G0438, Initial AWV is appropriate. You should not bill a subsequent AWV without the initial. I know you said logically but this is Medicare. And remember that an AWV is not a Routine Preventative Exam so if you perform a 99387 and document it you can bill the patient. Both can be done on the same day. Check with your local Medicare carrier for detailed information on billing these visits. Hope this helps –Manny

  39. Lori Thompson says:

    If a patient see their physician for their once in a life time IPPE Initial Preventive Physical Exam and 12 months later come back to see their physician for their AWV (Annual Wellness Visit), do we bill the initial G0438 (first visit, once in a lifetime visit) or do we bill the subsequent visit of (G0439)?

  40. Irina says:

    Hi Manny, I got confused a little. Patients is eligible for AWN G0438 ONLY in the second year of Medicare coverage? or during the lifetime as long as 12 month has passed since IPPE ( if pt is eligible) and AWN has not been billed before. For example if patient has Medicare Part B effective on 01/01/2003 and was never billed for AWN G0438 before, can I bill G0438 for 2011 visit?

    • Irina thanks for your question.

      The G0438 Annual Wellness Visit can be billed out at any time if the patient has never been seen for the AWV and it is after the first 12 months the patient became a Medicare recipient. For example, if the patient has had Medicare coverage since 2009 but the AWV has never been billed then use the G0438 code, not the G0439 Subsequent visit (as there was no prior G0438 for the G0439 to be subsequent to). There is no time limitation to the G0438 unlike the G0402 IPPE ("Welcome to Medicare" exam) and it’s corresponding once in a lifetime benefits.

      As always please be sure to check with your MAC and the guidelines at CMS: http://www.cms.gov/Outreach-and-Education/Medicar

      Hope this helps –Manny

  41. Mark Pfeiffer says:

    (con't from previous comment)
    I did a little research and discovered the following on the Medicare.gov web site under "Welcome to Medicare Preventative Visit" where it discusses "Your costs in Original Medicare": "You pay nothing for the yearly 'wellness' visit if the doctor or other health care provider accepts assignment. If you get additional tests or services during the same visit that aren't covered under these preventative benefits, you may have tp pay coinsurance, and the Part B deductible may apply." What is there in either a CMT G0438 or G0439 exam that is not covered in a CMT 99397 exam; and, why wouldn't I just be billed for whatever a CMT 99397 exam covers that is above and beyond the scope of a G0438 or G0439 exam? Am I being defrauded by my medical service provider, or am I just dealing with a coding department that is merely ignorant?

    • Mark, great question. I started to reply here in this comment tread but soon realized I needed more space to write so I put in into a post. Click on this link: http://www.capturebilling.com/am-i-just-dealing-w… . This will take you to the post where I attempt to answer your question. If I did not hit the mark please leave follow up questions and your comments on that post. Thanks again for your question. –Manny

  42. Mark Pfeiffer says:

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

  43. Mark Pfeiffer says:

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

  44. jan says:

    The word "wellness" throws us because most of our pts have a health issues. That's why they come to the Dr. to get help managing their illnesses. The preventative exam doesn't fit either: if they'd practiced preventative measures long ago, they probably wouldn't have diabetes, htn, hi-cholesterol, etc. Yet bill 99215 to Medicare for annual review of all their issues and make medication adjustments and do lab reviews, and EKG, etc, and the pt calls when they get the statement after Medicare's paid and they want their visit "rebilled with the wellness code — it's free. Medicare said so." Most of the elements for the G4038/G4039 are covered in the 99215 but there was so much that was medically necessary. It's hard to find a code that everyone's happy with, from pt to Dr. to biller!

  45. Laura says:

    Can a Medicare wellness visit be billed out of POS home, assisted living facility or nursing home?

  46. Jenny says:

    I am having problems with the medicare hmo’s more than anything. This is what I am billing the HMO–g0439 dx v70.0, g0403 dx v17.3, g0328qw dx v76.41, g0101 59 dx v72.31. I am getting a denial stating the procedure code is inconsistent with the modifier used or a required modifier is missing and the benefit for this service is included in the payment/allowance for another service/procedure. Help!!! We typically bill our preventative medicine visits as g0438 or g0439 and g0403, g0328 and if applicable g0101 59. Any suggestions?

    • Jenny, to try to help better answer your question, I will respond to each individually billed charge you mentioned:

      G0439 / V70.0 This billing seems appropriate. If this particular line item is denied then I would suggest double checking the frequency and date of coverage of the patient (for example, should this have been billed as a G0438 initial AWV instead, or as a G0402 IPPE?). Otherwise we frequently bill this out just as you have listed and receive reimbursement.

      G0403 / V17.3 The only appropriate time to bill out the EKG as a G0403 is in conjunction with the G0402 IPPE “Welcome to Medicare” exam. It is a once in a lifetime benefit. If a patient is seen for the AWV and the provider also performs an EKG we will bill out the EKG as a 93000 with a diagnosis that indicates the medical necessity of the EKG. For one of our Medicare Carrier’s there is a list of diagnosis codes that supports medical necessity. Please check your carrier’s website to find a list of appropriate diagnoses. Here is a link to one of our local carriers: https://www.novitas-solutions.com/policy/mac-ab/l…. Dx code V17.3 is not on this list.

      G0328-QW / V76.41 There are specific rules, please check CMS or your MAC website. Is CPT code 82270 (Stool Occult Blood) a more appropriate code for you to use? You may want to look into it. Also look at V76.51 (Screening for Colon Cancer). Please see the following link for additional information and note that CMS also indicates to contact the local Medicare Contractor for guidance for both the G0328 and the 82270: http://www.cms.gov/Outreach-and-Education/Medicar….

      G0101-59 dx v72.31. The Medicare Pelvic and Breast Exam G0101 has very specific billing guidelines: http://www.cms.gov/Outreach-and-Education/Medicar…. Although this code as listed on the quick reference chart can be billed with the V72.31, we’ve found that our Medicare Carrier does not accept this dx and requires any of the other diagnoses instead (V76.2, V76.47, V76.49). Please be sure to check with your local carrier.

      ***As always with billing Medicare for preventive services be sure to have the proper ABN completed, signed and dated.

      You can see why there is a trend for doctors to have Certified Professional Coders on staff and why practices are outsourcing their medical billing. Medicare is making it more complicated every day for medical practices. –Manny

  47. Storm says:

    What is the appropriate billing for care plans and the recerts. We are having trouble getting Medicare to pay anything on these. Can someone give me advice on what icd9 and cpt codes you are using?

    • We do have clients that we do billing for and have the following pointers for you:

      Appropriate billing codes for Home Health Certificates: G0180
      *Dx codes are used in order that is on the Home Health Certificate
      *Also the home health agency # that is on the right hand side of the certificate, must go in box 23 of your claim form, if not it will reject.
      *The DOS must be the date that is the start date on the Homehealth Cert .

      Home Health Recerts (G0179) do not pay with our local carrier so we do not bill for them.

      Example:
      The home health certification days are 12/29/2012-02/26/2013.
      The Doctor fills out another one on 02/27/2013.
      You would bill another G0180 for DOS 02/27/2013.
      You may only bill and be paid for 1 certification during the certification dates dates.
      Even if the patient switches agencies, Medicare only allows payment every 60 days.

      If there is an addendum or change of care plan, it is inclusive and you may not bill for it, hence why we do not bill G0179.

      We found the following information on our local Medicare carrier (Novitas) which has some great information about billing and the requirements for Care Plan and Certifications/Recerts.

      Novitas website: https://www.novitas-solutions.com/em/coding.html see Physician Care Plan Oversight Services and Physician Certification and Recertification of Home Health Services. Make sure to check with your local Medicare carrier for specific rules in your jurisdiction.

  48. Rebecca says:

    I'm having the same issue as Christine. We are billing G0438 and 99214 with 25 modifier and getting them all denied. We billed with V70.0 as the primary dx code. Medicare is no help at all on clarification. Do I have to have v70.0 secondary?

    • We have not had this denied as long as everything is billed properly with appropriate modifiers and diagnoses. We frequently bill out either the G0438/G0439 V70.0 with an office visit with modifier 25 for additional distinct problems. We are reimbursed by Medicare for both the AWV and an office visit if billed out properly.

      However, we have come across the following problems:

      Billing out either the AWV or IPPE and getting a denial for not using the appropriate CPT code. For example we billed out a G0438 but it should have been a G0439, patient was seen and billed for the G0438 by another provider. We corrected the claim and received payment. Also we had billed out a G0438 but should have billed out the G0402 instead, corrected and got this reimbursed by Medicare. Note that we billed these all with the V70.0.

      Also frequency/date of service could be an issue – have you double checked the dates of service between the G0438 and G0439, or between the G0402 and the G0438?

      What is the exact denial code that you are getting on the EOBs?

      We have found the carrier websites to be very helpful. In our area we bill out to both Trailblazer and Novitas. Have you had any luck contacting your local carrier provider representative?

      Also see the CMS website and Guide to Medicare Preventive Services.

      • Valerie says:

        Manny,
        I am having a similar problem where I billed out an AWV and a 99204. Medicare paid the 99204 but said the G0438 was mutually exclusive. Any thoughts?

        This is how I billed it:
        V70.0 – G0438
        715.96, 780.52, 401.9 – 99204-25

        Thanks,
        Valerie

        • Valerie, there has got to be more to this Annual Wellness Visit (AWV) denial because the way you have it coded should pay. We have no problem getting paid for claims that are similarly coded.

          What was the denial code you received from Medicare? It could be something as simple as frequency (since this is a new patient to your practice they could have had the G0438 with another provider and you need to bill out the G0439 instead) or missing a referring physician, etc.

          Let me know what you find. –Manny

          • Valerie says:

            It's a United Healthcare Medicare policy. I just called them about it to see if they can explain the denial in more detail and all she could tell me is that the G0438 is mutually exclusive to the 99204-25.

  49. Shelly says:

    A provider has ordered labs on a patient that will be seen on his 65th birthday for the Initial Medicare Wellness visit. What diagnosis does the provider use for these labs? Medicare will not accept the V70.0 code.

    • As labs are not considered a part of the IPPE or AWV submitting them with the V70.0 and not showing medical necessity would definitely result in a denial for non covered, routine services. As Medicare has such stringent requirements for billing, the labs can only be billed if medical necessary and appropriate versus any annual code, based on their documentation.

  50. christine says:

    Hi, the dr. that I bill for wants to bill a G0439 with and office visit 99213 using a 25 modifier. I called medicare and they said I can't do this but the doctor insists this will get paid. Have you ever heard of this?

    • We have never heard of this being denied as long as everything is billed properly with appropriate modifiers and diagnoses. We frequently bill out either the G0438/G0439 with an office visit with modifier 25 for additional distinct problems. We are reimbursed by Medicare for both the AWV and an office visit if billed out properly.

  51. Gigi says:

    Hey Manny so im setting up a patient for G0438. Can I just bill this with dx V70.0 or do I have to use a cpt code 99385-99387 with that? Also if both need to be used do I have to add a modifier 25?

    • Yes you can bill G0438 with V70.0. If you are also performing a Routine Preventative Medicine Physical Exam for a Medicare patient (which is different than the Annual Wellness Visit-G0438) you can bill the age appropriate 99387 or 99397 CPT code also with a V70.0 diagnosis. A modifier 25 is not needed. Check with your local Medicare carrier for their specific rules.

      • Tricia Audiss says:

        Medicare does not recognize the 99387 or 99397 code, G0438 is this Preventive replacement code. You are incorrect Wellness and Preventive are the same.

        • Tricia you are correct that Medicare does not cover 99387 (new patient) or 99397 (established patient) Routine Preventative Medicine Exams, typically referred to as Annual Physicals. If this non-covered services is performed the Medicare patient can be billed directly and an Advanced Beneficiary Notice (ABN) is not needed. Note that some secondary insurance companies do cover the routine physical.

          Many providers believe that the Annual Wellness Visit (AWV, G0438 and G0439) is the same as a Routine Preventative Exam. My guess is they are going by what they may have heard in the media that Medicare covers check-ups. The media has been misinforming doctors and patients. A Routine Preventative Exam and AWV are two different services. The AWV has very specific questions that a providers must ask and properly document in order to be able to bill for the service. Take a close look at the requirements in the CMS MLN Matters Publication MN7079 and then take a look at the requirements for 99387/99389 Routine Physical in your CPT book and you will be able to see that the two services are completely different.

          I foresee providers documenting the AWV as a Routine Physical and not documenting what is required by the AWV, getting audited and having to return the money (plus penalties) to Medicare because the documentation does not support the G0438 coding.

          If your physicians are performing both a 99387/99397 and a G0438/G0439 they should bill for both and get paid for both. –Manny

  52. Jocuripro says:

    Medicare G0438 – G0439: New Annual Wellness Visit Codes is an impressive share. Thank you for this article.

  53. Haley says:

    If a patient comes in for lab review would that be considered a well check visit? I dont believe so but some others are saying it is a well check.

    • If a patient is coming back to review their labs it probably means that there is an abnormal result the physician wants to discuss with the patient. You may have to look at the chart notes to be sure but this is probably the case. It should not be considered a well check.

  54. Shawn says:

    I would like to ask what Dx would you code to go with G0438/G0439?

  55. frank says:

    How do you bill EKG (cpt and dx) with G0439?

    • Frank, bill the EKG (93000) with a dx that indicates medical necessity if appropriate. Medicare is very specific about which diagnoses indicate medical necessity for this CPT code and can easily be found on either the CMS.gov website or at your local MAC website. For our area we bill to Highmark and on their website it is easy to do a search on a specific code and billing instructions. If the EKG is done because it was not medical necessity, according to Medicare, then it will not be reimbursed and the EKG will have to be written off. Hope this helps.

      Routine EKGs are not covered. The only exception is the Welcome to Medicare EKG. There is additional information on our website about Welcome to Medicare billing: http://www.capturebilling.com/welcome-to-medicare

  56. frank says:

    Last year we were billing G0438 and G0403 (EKG) with dx V70.0 and both were paid. This year, we billed, on the same pt, using G0439 (dx V70.0) and 93000 (other dx) and the 93000 was denied. How do we bill EKG with a G0439?

  57. tracey says:

    Medicare patient biled 99214 w 401.9 ,250.00,585.1,v58.69 also had 93000 for 401.9 . having a problem w meddicare paying ekg but if I add 59 modifier it will pay . Is this correct?

    • Medicare will only allow an EKG for diagnoses that indicate the medical necessity of the EKG. Medicare is very specific about which diagnoses indicate medical necessity and for our MAC, Highmark does not allow for the 401.9. Please check either the CMS.gov website or your local carrier’s website for specific billing information and medical necessity for the EKG. For example, based on the diagnoses you’ve provided the only applicable diagnosis is probably going to be the V58.69.

  58. mirna says:

    HI Manny could you please tell me if there are any cpt codes to bill medicare for tetnus shot or dtap? I can not get those to get paid by medicare if i bill under cpt code admin 90471.

    Thanks Mirna

    • These vaccines are not covered by Medicare although secondary insurance may pay. If secondary does not pay we bill the patient. An ABN is not needed but you may want to use a voluntary ABN just to let your patients know they may be responsible for payment.

  59. Carol says:

    Regarding the PT AWV: we are looking for clarification on a point. Can a MC patient see more than one provider in a years time for the AWV? that is to say can he see an MD for one AWV and the next week see a PT for a review of functional ability and be cover by both visits?

  60. Carol says:

    I work in the Rehab dept of a small rural hospital. We have a few questions regarding the Annual Wellness Visits (Initial and subsequent). A Physical Therapist/Occupational Therapist is medical professional and a licensed practitioner, so it would appear that we may perform the annual visits for our rural population. 1)Do we need an MD reperral for this as we otherwise do? 2)What is the typical re-embursement for these visit? 3)Will Medicare cover for an MD visit as well as a PT visit to one individual within the same time frame?

    • After reading the definition of a medical professional it does look like a Physical/Occupational Therapist would qualify. I have not come across that. In addition there are special rules for rural hospitals that may apply. At any rate you can rest assured that the claim will deny if if they are not considered an Eligible Provider. Yes, as with other Medicare claims you should have a referring provider.

      The reimbursement for the AWV depends where you are located but the national average is 166.44 for G0438 and $ 110.96 for G0439.

      The Annual Wellness Visit should be paid independent of any other service provided on the same day. Hope this helps and gets you pointed in the right direction.

      • Carol says:

        Thank you for getting back to me. I am curious about the special rules for our being a rural hospital. Can you tell me about that?

        • We don\’t deal with rural areas much but in my reading I have heard that the government does have some special programs in these areas that may be undeserved. You may want to talk to your Medicare carrier rep to see what information they have.

  61. Erika says:

    I have been trying to get a correct Medicare code for a direct face to face homcare patient code. I have been billing 99366 to Medicare and they are denying it with a denial code stating “This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service /procedure has not been recived/adjudicated.” I have read and read and haven’t come across what I am looking for please help me.
    Thank you;
    Erika

    • Erika, upon researching this CPT code there are specific guidelines that must be met and we just want to make sure the following criteria is met:

      99366
      Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified health care professional

      ***Are you billing for a nonphysician?

      Face-to-face participation by minimum of three qualified people from different specialties or disciplines

      ***Is there a minimum of 3 qualified people from different specialities? If so, who is billing for each provider? Are you billing for all three providers? Have you coordinated billing with the other providers if applicable?

      Only participants who have performed face-to-face evaluations or direct treatment to the patient within the previous 60 days

      There are several CPT codes for home visits. Do any codes from 99341 – 99350 or 99500 – 99602 apply?

      I don\’t have enought information to give you a good reason why you are getting those denial codes but hopefully the questions I raised can point you in the right direction.

      • Erika says:

        Medicare's new guideline is requiring a face to face visit with the homecare patient to justify their actual needs in having home care agencies to come to their house daily/weekly/or whatever they are assigned. Our doctor is just the patient's primary care physician that signs off on the patients care plan, home care orders, reviews and changes pt's medication/treatments per home care agencies request. We talk to the patient/caregiver/agencies if our doctor has 30 min. of documentation per month then we can bill G0180,G0179, G0181.

        What we need is a code to bill when the home care agency requires an in office face to face with the homecare patient to agree on the need for home care and the services they are going to provide. The patient is seen in office by the physician.

        I dont believe 99341-99350-99602 apply because that in performed in the patient's home and we perform the face to face in office.

  62. Fara says:

    I have been erroneously billing G0439 last year (2011) for the AWVs and Medicare paid. Now it’s time for the same patients to come back in for another AWV and I have been billing the same G0439, but Medicare is now denying it. Do you think Medicare is denying this year’s G0439 because I should have been billing G0438 for all those first-time AWVs? What should I do. I am kind of thinking I may have to refund Medicare all of the payments for the G0439 last year (2011-because I should have been billing G0438 instead) and then rebill with the G0438 for all those patients in 2011. What do you think?

    • Most likely Medicare is denying the G0439 because the G0438 should have been billed in 2011. As these codes were only effective beginning 1/1/11 the appropriate CPT code to bill for the AWV is the G0438 and the subsequent G0439 in the following year. Also make sure that you are checking for frequency, if the initial AWV was billed out less than 12 months ago then that might also explain the denial. In our experience, it would be appropriate to rebill the visits as the G0438 if appropriate and then contact Medicare with the error and ask them if they will initiate retraction based on the corrected claim or if they want a refund issued to them. Some of the MACs are great about direct contact. We have been able to call Highmark Medicare in our area and deal with redeterminations using their dedicated redetermination phone number. We also correct claims via the redetermination center. Their representatives are great about advising us as to how they want specific things handled. Giveyour local Medicare Carrier a call.

  63. Kelli says:

    I have a provider that is doing some of the wellness checks and she is aksing me if this fees could be applied to the deductible for the patient or it this is something that does not get applied to the patient deductible?

    • That solely depends on the patient’s individual insurance policy. In our experience we have seen deductibles on both wellness and sick visits and it depends directly on how the insurance company processes each individual’s claim. A way to address this is to check the patient’s eligibility on the insurance websites. The websites are usually a great guideline and may give you additional information, especially on deductible percentages and whether or not wellness visits require a copay – however, we never really know until the claim is actually accepted, processed and paid by the insurance company!

  64. Pat says:

    When is 99397 used vs G0438? Which would be the best way to be paid since some folks balk at 99397.

    • With Medicare it’s never how to code to get paid it is what procedure was performed and was it medically necessary. Then you work on getting the claim paid properly which may mean getting payment from the patient. That said, 99397, Routine Preventative Visit is completely different than a G0438, Annual Wellness Visit (AWV). You can actually bill for both codes at the same visit if you performed both services and documented properly. The post above outlines what is part of the Annual Wellness Visit. Your CPT book should list what must performed and documented for a 99397 which is a non-covered service. The practices we service bill for both visits and the patient pays for the 99397. There are also times when there is a Well Woman Exam given at the same time and we that we carve out of the 99397 and bill Medicare a G0101 and Q0091.

  65. Keke says:

    Good posting. Thank you all. I have a question about the G0439. I added a Modifier 25 to it and added the 93000 with a ICD for 401.9. I got a rejection from Medicare saying the Modifier is not right. Can I add Modifier 59 and resubmit. Also, if the Doc did a male exam can I add G0101 to it. Need help.Thank you.

    • Keke, I have a few questions for you before we can point you in the right direction. First of all, a modifier 25 should not be necessary and is usually not billed out on the G0439. In fact, depending on what was billed, a modifier should not be used. What are the exact services that you billed out for and what are the diagnoses?

      The issue with the EKG may be the diagnosis. Our local Medicare carrier has a list of diagnoses that indicate the medical necessity and usually HTN is not billable. Check with your local carrier.

      The G0101 is for the female Pelvic and Breast Exam. Was the exam done for the Digital Rectal Exam? Let us know exactly what you billed and maybe we can help you!!

  66. Kari says:

    Kinda confused on the "what is included in an AWV w/PPPS?" from MLN matters, pg2-3. Does all 11 of these have to been be done at the visit. And is it true this these codes (G0438,G0439&G0402) can be used at any speciality Dr. Also,can you bill a G0438/G0439 w/a pap and pelvic.

    • Yes what is listed in MLN Matters is what you must do and document in order to bill a Annual Wellness Visit (AWV). The only practices we have using G0402, G0438, and G0439 are primary care practice. You can bill the AWV with a pap and pelvic. You can also bill a routine physical 99387 or 99397 if it is done. So technically you can bill the following:

      99387 Routine Preventative Medicine Exam
      G0438 Annual Wellness Vist
      G0101 Pelvic and Breast Exam
      Q0091 Pap

  67. Samson says:

    If a patient had a service with 99385 and after 4 years he again come for preventive visit, shall we bill 99385 or do we consider it as periodic visit and bill 99396. (Since if the patient have no service between 3 years we consider it the patient again as new patient)

    Thanks
    Samson

    • Samson if a patient has not been seen in your office for any reason for over 3 years then that patient would be considered a new patient and it would be appropriate to bill a new patient CPT code. Also keep in mind that with the preventative medicine codes you not only have to choose new or existing patient but you must also consider the patients age when choosing the appropriate code. Let me know if this helps.

      99385 – New Patient Preventative Medicine Visit (Age 18-39 years)
      99396 – Established Patient Preventative Medicine Visit (Age 40-64 years)

  68. mildred says:

    I would like to know the right way to bill balance test to medicare, the are bunduling the cpt codes 92270 and BCBS, when I call Medicare they said go to cci, but I can not find anything, can you help me with that?

  69. kiran says:

    Hi all can I bill G0402 medicare with v70.0 and with 99204 ?

    • Yes you can bill G0402 with a V70.0. As for billing a 99204, per CMS "Medicare payment can be made for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201-99215) billed at the same visit as the IPPE when billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member." Make sure there is an appropriate problem oriented, medically necessary diagnosis for your 99204.

      • Victoria says:

        Hi Manny. I found it helpful on the CPT book that also states "If an abnormality is encountered or preexisting problem is addressed IN the process of performing this preventive medicine evaluation and management service, and IF the problem or abnormality is significant enough to require additional work to perform the key components of a problemm-oriented E/M service, then the approriate Office/Outpatient code 99201-99215 should ALSO be reported. Would you first code the E/M w/mod 25, then the G-code or the reverse? Thanks

        • Julia says:

          Manny I was curious as well to whether use the 25 modifier on the line with 99214 or the G0438 when these 2 services are performed in the same day, Or does it even matter?

  70. Rupert Hulslander says:

    Some really fantastic posts on this website, thanks for contributions.

  71. Mark says:

    I want to say thanks for taking the time to explain the Welcome to Medicare exam to me. You guys took time out of your busy schedule and helped me to understand it . Thanks again.

  72. doc says:

    Let's face it , G0438 involves only vital signs, weight, and height, and then talking to the patient; it is all about risk, and not about illness or hands on physical exam. I have been adding it on to a non physical exam/routine follow up visit., when we sit and talk about what Medicare thinks we need to discuss. What is your feedback?

    • Manny Oliverez says:

      We have come across physicians that were doing a full physical exam becasue that is what they thought an AWV was.

  73. sally says:

    We have been trying to get the EKG paid with the g0438 it was a medically necessary icd code and still it was denied we also tried with the 59 modifier not sure what else to do I contacted medicare they referred me to their web site I am from a PCP office anyone know how else to get the ekg pd

    • asra says:

      Sally,

      They don't pay with mod 25 for 93000 when billed with g0438. So I tried 59 mod. and it did work . they paid approx $14 and made $5 as coins. Maybe you should send it for reconsideration.

  74. I have a question. I heard that these wellness codes G0438-G0439 can only be billed three years after they become new to medicare or after you bill the first one welcome to medicare? Is this true or can you bill every year? Thanks

    • When a Medicare patient first enrolls into Medicare, during their first year they can have a “Welcome to Medicare” exam, G0402. This exam must be done within 12 months of enrolling. The next year the patient can have an Annual Wellness Visit (AWV), G0438 first AWV. In the following years you will bill G0439 annually for the Subsequent Annual Wellness Visit.

      Now if a patient has already had their “Welcome to Medicare” exam or if they are no longer eligible because it is beyond 12 months of enrolling into Medicare, then you can use the AWV G0438 for their first visit.

      Please note there are different requirements for each visit type and that the Annual Wellness Visit is NOT a Routine Complete Physical Exam. It may still be appropriate to bill a 99387 or 99397 if that service is performed. The patient will be responsible for the fees as Medicare does not cover most routine preventive care.

      Hopefully this answeres your question. If not shoot me back another comment.

      • Mirna says:

        Hi Manny can I bill 99387 or 99397 to medicare with v70.0 to medicare and with G0438 will i use v70.0 dx? Another question I have do you know if there such thing a mini mental status exam cpt code? I work for geriatric doctor so we have lots of thos patients.
        Thanks Mirna

        • Manny Oliverez says:

          Yes you can bill both with V70.0. Remember that these are two different exams. If you are performing the services on the same day make sure they are documented properly and separately. I have heard that some practices will bring patients back on another day to do the 99387. I have not heard of a mini status exam CPT code. That may be something that could be a separate visit if there are some significant issues.

      • Victoria Scott says:

        Manny,
        I've been reading my code books trying to figure out what constitutes an "Annual Routine Preventative/physical exam" (99311-99397) and AWV…. I'm having a hard time determining when to use the Gcodes and when to use the preventative visit codes. I've read your VERY helpful blogs about it but am completely confused when it boils down to the difference of the two. thanks a million!

  75. JAMEEL KHAN says:

    I attended an annual HOMNY meeting in which the G0438 and G0439 codes were discussed. I work at an Oncology & Hematology practice , and it was not stated by Mr. Bovoso from Medicare that it only pertain to Primary Care billing for these services. I did a test on a patient who had Multiple Myeloma already established and Medicare paid us for this procedure.

    Please shed some light since the information that was given was not appropriately addressed by the above mentioned.

  76. Michelle says:

    I just called mEDICARE REGARDING THE SAME PROBLEM. i WAS TOLD THE 93000 WAS BUNDLED WITH G0438. i I ASKED DOES THIS NEED A MODIFIER AND SHE SAID YES. i THEN ASKED WHICH CODE REQUIES IT AND WAS THEN TOLD TO LOOK AT THE ANSI TABLE COLUM 2. i STILL CAN NOT FIND. HELP.

    • The only time an EKG is covered by Medicare is with the IPPE. Bill out the EKG with the appropriate G code (G0403, G0404, G0405) – when it is a screening EKG as a result of a referral from an IPPE.

      93000 can be billed out with the AWV G0438/G0439 but needs to have a dx that indicates medical necessity as an EKG with a diagnosis of V70.0 that may have been sent in conjunction with the G0438 will not get paid – Medicare doesn’t cover preventive services meaning EKG with dx V70.0. It will definitely deny as inclusive.

      The only reference I’ve found on the CMS website is here on page 24 about half way down the page: http://www.cms.gov/MLNProducts/downloads/mps_guid

      “Should an additional medically necessary EKG in the 93000 series need to be performed on the same day as the IPPE, report the appropriate EKG CPT code(s) with modifier – 59. This will indicate that the additional EKG is a distinct procedural service.”

      Good luck with the ANSI Table Column 2.

    • sam says:

      Modifier 25 is used to un bundle the 93000 (ekg?) also you need a referring Dr. on HCFA form I for get what box it is but medicare will not cover unless you a referring Dr. Even if you do them in the same office and it is the same Dr. You still have to but the billing Dr.'s name in the referring Dr. spot to have it covered.

    • MARCY says:

      USE A 25 MODIFIER ON THE OFFICE VISIT LINE. IT WORKS EVERY TIME.

  77. Teresa Hatfield says:

    I am in an Urgent Care and recently had a G0438 denied due to POS, I asked Medicare and the rep said it is allowed but you must use a modifier, I have looked and I am not sure which modifier to use,

  78. Tina Richwood says:

    We are having the same problem but it is not due to the dx code. The comment at the bottom of the eob states that " this service/procedure requires that a qualifying service/procedure be received and covered.

    What does that mean? Up until now 93000 was being covered with the g0438 and our doctor sometimes is able to bill a regular office visit along with the g0438 due to the extensive visit/medical problems a patient has.

    When I try to call Medicare they are unwilling to help me, they just say look at the website. Thank you in advance for your help with this.

  79. [...] we are all aware, Medicare now allows for the Annual Wellness Visit (AWV) G0438 or subsequent AWV G0439, but how does this relate to an annual Well Woman Exam?  IT [...]

  80. phyllis wilson coady says:

    When billing G0438 or G0439 a wellness visit with a EKG 93000,we billed G0438 and 93000 and placed a medical dx on the 93000 yet was still denied for the EKG does the EKG need a modifier?

    Phyllis

    • Phyllis a modifier is usually not needed for the 93000 EKG. One of the problems we come across when an EKG is denied by Medicare is that the reason for the test, or diagnosis, is not considered medically necessary. Check the Local Coverage Determinations (LCDs) of the Medicare carrier in your area. They should have a list of ICD-9 codes they deem medically necessary. If the diagnosis is not on that list then it is considered not medically necessary and the EKG will not pay. Make sure you have a valid ABN on file in those cases to be able to bill the patient.

      • Jim Ngo says:

        Manny, I am unable to find what is considered an interpretation of an ECG. Is “normal sinus rhythm” enough to be an interpretation? If no, then how many items need I document (rhythm, QRS, intervals, ST segments, etc) to be considered an interpretation.

        • Here is some some information from Medicare CAC, June 1995. Its talking about the Emergency Department but I should not make a difference in regard to documentation.

          EKGs

          • Document the interpretation of the tracing in a separate section of the ED chart.

          • For EKGs, the interpretation must include appropriate comments on any 3 of the following 6 elements: (1) the rhythm or rate (2) axis, (3)intervals, (4) segments, (5) notation of a comparison with a prior EKG if one was available to the ED physician, and (6) summary of clinical condition.

          “An EKG with interpretation must have the full graphic tracings with formal written or printed interpretation on file for review. The interpretation should appear on the designated sections of a page formatted EKG or written in the clinical records. Interpretations should include appropriate comments on rhythm, axis intervals, acute or chronic changes and a comparison with the most recent tracing. While every single parameter is not required for each tracing, the appropriate measurements must be mentioned if the purpose of repeated EKGs is to monitor the effects of a given parameter, e.g., the QT interval.

          For example:

          – EKG reveals normal sinus rhythm, no axis deviation, no acute changes.

          – EKG reveals normal axis and intervals, no previous EKG for comparison.

          – EKG reveals atrial fibrillation, rapid ventricular response, non-specific ST-T wave changes

          – EKG reveals normal sinus rhythm, normal axis, T-wave inversion in V3 and V4 and T-wave flattening and high laterally. No EKG was available for comparison.

          – EKG reveals normal sinus rhythm with rate of 66, PR and QRS intervals within normal limits, some QRS complexes in lead III and T-wave abnormalities in I and aVL, but when compared to prior EKG there is no acute change noted.

          RHYTHM STRIPS

          Rhythm strip interpretations cannot be billed when they are done at the same time as a full EKG. However, they can be billed when performed at a time different than the EKG and when the medical necessity of the rhythm strip is clear. When clearly necessary, each may be billed separately. Documented change in a patient’s condition or response to medication would allow separate reporting of a rhythm strip after an EKG was done.

          Hope this helps.

    • j biemuller says:

      needs modifier 59

  81. [...] is a Welcome to Medicare visit and how do you bill for it?  Let’s see if I can help and explain and point you in the [...]

  82. Excellent reference, thanks.

  83. Jean I need to clarify – you are mentioning that the Doctor saw the patient for the IPPE (G0402) but the corrected claim you sent was for the AWV (G0438). Just want to double check with you about what exactly was billed as these are two distinct codes.

    In our experience modifier -25 submitted with the 99214 billed in conjunction with either the G0402 or G0438 is usually paid by our MAC. However, we have had denials when we’ve submitted a 9921X-25, a G0402 (or G0438/G0439) AND another procedure, for example 69210 Cerumen Removal. In this case then we received a denial for the 9921X but were reimbursed for the other two charges. Based on our MAC and CMS guidelines this denial was correct.

    Were there any other procedures or tests billed out on that same date of service? –Manny

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