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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

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

G0438 Annual Wellness Visit, Initial (AWV)

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

G0439 Annual Wellness Visit, Subsequent (AWV)

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

What is included in an Initial AWV with PPPS?

  • Medical and family history
  • List of current medical providers
  • Height, weight, BMI, BP and other appropriate routine measurements
  • Detection of cognitive impairment
  • Review risk factors – Review of functional ability
  • Establish a written screening schedule for 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 your local Medicare carrier’s website. You can also contact them directly.

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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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393 Responses to Medicare G0438 – G0439: Two Annual Wellness Visit Codes

  1. I have an URGENT QUESTION Regarding billing for “PREVENTATIVE CARE” We have been billing a few cpt codes: These tests are showing medical necessity, but are considered to be PREVENTATIVE IN NATURE: as all of the testing that we are doing is to PREVENT ADDITIONAL ISSUES with the patients: Such as Neuropathies for our Diabetic Patients, Cardiac Issues with our patients with Cardiovascular issues

    Can I bill 93923, 95923, 95924,

  2. I also wonder why on the Medicare eligibility website it has a modifier 26 next to the G0438 and G0439 …it is a Professional component…when would that be used?

    • Lisa I can tell you I would never use a 26 modifier on an AWV code. Can you please share the link to the page you found the info on? Post it as a reply to these comments. I would like to check it out.

      • It actually was when I went thru connex to look up pts eligibility ….it used to be called entitlements now eligibility …lists what they are eligible for then next to it there is a column with modifiers,eligible date ect …both of the codes have the mod 26 next to it

  3. Hello Manny,
    I’ve been reading and studying these post for a couple if days. You are a wealth of knowledge. I am new at coding and have several questions: (I’ll start with a couple as not to overwhelm)

    1. I understand the difference between the IPPE G0402, 1st AWV(G0438) and subsequent AWV (G0439. I was wondering which Dx codes should be used with the visit…Z00.00/ plus any Chronic Condition codes? I understand that Z00.01 can only be used if an abnormal finding was found on that day.

    2.I have CAHABA GBA InSite web portal which allows me to check patient eligibility (entitlements) for preventative services. On the page I can see, it shows the date the patient is eligible for certain services. If it says the patient is eligible for the IPPE on the same day they became a Medicare beneficiary (for example in 2012), then I assume the patient never received this G0402 IPPE visit and can longer receive it since it has to be done within the first 12 months on Medicare. I also see that her G0438 & G0439 has an eligibility date of 1/1/2013. It also has a Modifier column on the screen which states 26. What does this 26 mean? (I know that it means Military treatment facility in the CPT book but she isn’t Military) And do we perform the G0438 with the Dx code Z00.00 plus any chronic conditions?
    Thank you for you help. I’ve researched for days trying to find a place to ask questions.

    Sincerely,
    Constance

  4. Can we bill an annual wellness exam and an E & M code (ex 99214) for the same patient, on the same day, in the same office setting, but with different providers within the office? One provider saw the patient for the wellness exam and another saw them for a checkup.

    • Yes you can bill for both an AWV and an E&M code. In your scenario you indicated that another doctor saw the patient for a checkup. By checkup if you mean a routine physical exam its not covered by Medicare and you would bill the patient. If female and a pap and breast & pelvic exam were done then you would carve those services out of the checkup and bill that portion to Medicare.

  5. I have providers wanting to report an AWV along with a problem oriented visit and a physical examination on the same date for those that carry insurance that will cover the physical Exam. I have not seen this done and my concern is that too many components of the PE and the AWV would overlap to support reporting both services. Does anyone have any reference sources that would support reporting or not reporting all three together. Again, concern is with the CPE and the AWV – same date.

    • Hi Eileen,

      I am a consultant and I help practices launch internal AWV programs. Any time that my client wants to do this I always advise them that proper compliance would be for the PE to be completed and billed on a separate visit (preferably on a visit AFTER the AWV has been done). Every year the AWV can be used for screening purposes (along with a regular problem oriented visit), and then the PE can occur on the patients next visit. Rationale being that the AWV should have established a ‘goal’ for what conditions or risk factors would be addressed for the next 12 months as the PE has patient edu components. See how it all comes together?

      Chris

      • Chris great advice. We do have a practice that has done the AWV, a PE and a problem-oriented visit all on the same day. The documentation is separate for all visits. The provider uses the AWV as a’goal’ like you indicated and then goes on to perform the PE and at times, if warranted, a problem visit.

        You did mention proper compliance is that the PE is to be performed on a separate visit. Do you have a link with documentation from CMS on this that you could pass along?

  6. Can anyone please tell me exactly what documentation is required for a medicare wellness visit? I am new to this and I am getting differing answers from my management.

  7. Hello,
    I am wondering if anyone knows where you can find examples of when an E/M code can be billed in conjunction with an AWV (G0438 or G0439). I want to make sure that we are billing E/M services when appropriate. Also, any information in regards to what documentation is required above any beyond the AWV note would be helpful.
    Thank you

    • Leah,

      An E/M code can be billed in conjunction with an AWV anytime that a patient presents with a symptom that requires diagnostic evaluation by the physician, is medically necessary, and is separately identifiable.

      As an example, say a patient is being seen for an AWV and they have a severe cough that they also want addressed. The doctor can address this separately at the time of the visit and both services can be paid (for example G0438/9 with Z00.01 and 99214 with J44.9). This example uses unspecified COPD as an example of the ‘sick visit’ reason.

      With regard to documentation what do you mean by AWV ‘note’? There is actually quite a bit of documentation required for Annual Wellness Visits. Can you be more specific?

      Hope this helped

  8. Do Medicare Annual wellness visits have to be done in clinic. Can they be done over the phone or at home such as home visit?

  9. We are getting refund requests from UHC Medicare Solutions for G0439 visits. We filed with ICD10 Z00.00 as always – they paid the claims and now they are telling we used the incorrect ICD-10 code, although they can’t tell us what code they will accept. Suggestions from anyone??

    • the only other code you can use is Z00.01 which is abnormal physical- and we determine that in our office if the patient requires follow up visits after that physical then they are abnormal.. I rarely use normal except for younger adults

  10. Thoughtful piece – I learned a lot from the facts. Does someone know where I would be able to obtain a fillable PDF Calendar example to work with ?

  11. Do you have to use a modifier for G0438 if you are providing this in conjunction with 99497? Do you need a modifier for the 99497?

  12. Hi Manny,

    I we are doing the AWV at our practice and we are billing as follows CPT/Mod/Dx:

    G0438/Z00.01
    G0444/33/Z00.01
    9949733/Z00.01
    99213/25/X

    Now I know that G0444 doesn’t get paid with G0438 which is fine but what is interesting is that Medicare will pay for G0438, 99497, and E/M for a few…..but most come back just paying G0438 and 99497.

    Why would this be? Reason we are given is a ’49’ saying E/M isn’t paid because it is a preventative service??? 😳

    • You can not use Z0000 with Medicare and Medicare plans as they do not pay for preventative services, you can only use diagnosis codes. Make sure Z0000 is not listed anywhere on the insurance claim form or it will get denied.

    • Hi Manny you can disregard my last comment and question turns out the docs we’re also using Z00.01 on the E/M which of course would cause it not to be paid as that is not a problem related diagnoses.

  13. The TB test was 86580 with the admin code 96372 we also billed G0439 . I will remove the 25 modifier and see if the G0439 will get paid.

  14. I billed a G0439 with a 25 modifier on the G0439 also on the same day we billed 86580 TB and 96372. I was denied by medicare for the following reason . The procedure code is inconsistent with the modifier used or a required modifier is missing. Should I not be billing for the 96372 administration fee . or am I using the wrong modifier . There are asking me to resubmit a new claim with the requested information. Any info would be greatly appreciated.

    • SANDRA YOU MAY NOT USE THE MODIFIER 25 WITH THE CODE G0439. I AM ASSUMING THAT “TB” YOU MENTIONED IS NOT A MODIFIER THAT YOU USED ON THE CLAIM. IF IN THE AFFIRMATIVE, JUST BILL THE CLAIM WITHOUT THE MODIFIER 25 ON G0439.

    • I don’t think you need a modifier code for straight Medicare if it is during the G0439 visit. If it is a level 3 then you do use the modifier code

      • Becci we have been using the modifier for years… if they are Medicare or replacement plans doesn’t matter. if you read my initial comment below it has been happening this past few months, and I wasn’t the only person who responded. So this is a new issue.

  15. So since August we have always had no problem with G0439 with a 25 modifier if we are doing any vaccines in office or other procedures we can charge for…but our new EMR system this year keeps pooping this up now:
    08/15/2016 AUTO SCRUB PRIMARY HOLD
    Rule: Procedure Code/Modifier Mismatch [359]

    [Medicare] Modifier 25 is not listed as reportable with procedure G0439. Please review the procedure coding and modifier usage on the Claim Edit screen.
    To help you resolve this issue, more information on modifiers that are appropriate for procedure code G0439 can be found in athenaCodesource.

    I go to their code source and all I see now is a 99 modifier which I have never used…anyone else having issues or is it just Athena’s EMR

    • Marcie,

      Did you get any resolution to this? I’ve been having the same problem and contacted Athena and they said maybe medicare changed their rules. They have not.

      • No I have not- I have tested a few claims with sending w/o the modifier so I can keep tabs on and some with the 25- and having to force drop with a CCO – I agree you think we would have heard this at the beginning of the year not in the middle!

      • Kristen I went to look at the charges I have done with and without the modifiers and both types of claims have been paid. I just do the CCO override on Athena until they fix their mess…because it proves no point.

  16. Manny,

    I was recently advised to consider adding the AWV to our SNF providers list of things to do. I reviewed several of your past posts to see what you thought. I do not see answers to the SNF posts. So I will ask a different way.

    Does the place of service matter with the AWV or the IPPE? (I do see the post on home health, thank you. I am most interested in SNF if you have this information.)

  17. We have a patient that had her Welcome to Medicare (G0402) in July of last year. Of course she’s new to us and said she hadn’t had a physical or anything of the sort in the past few years. Because we had new front office staff, they did not call Medicare with the question prior to the patient visit. We billed the G0402 and was denied. We refiled with G0438 and have been denied again because we did the exam in April of this year and it’s been less than 12 months. Are we able to bill the G0439 or are we just going to have to bite the bullet for this one?

    • Jessica, first of all a G0402 is different than a G0438. Did the provider perform and document all the elements of a G0438 when the Welcome to Medicare exam was done?

      There is still a 12-month minimum time when performing any Annual Wellness Visit so a G0439 would not fly.

      Now with an AWV you do not need an ABN signed so you are able to bill the patient for the visit and get paid.

      So you can either bill the patient the full amount or start biting that bullet and write off the claim.

      • Thanks so much for the timely reply. I understand the differences between the codes. The provider had adjusted the note to reflect the different code being billed since the correspondence had originally come back within 14 days of the pt visit. Yes, the provider did document everything associated with the G0402 and G0438 because he wasn’t sure which one he was doing originally.

        I did not know that about the AWV and ABN… thank you

    • Kathleen that is not true. A GYN can do an Annual Wellness Visit. My guess is that they don’t want to becasue they are afraid that the primary doctor may have done the visit previously and the GYN will not get paid.

      This visit can only be done once every 12 months. We have had doctors perform the service only to find out later that the patient had a wellness visit from another doctor within the 12 month period resulting in the claim being denied and the doctor not getting paid. And yes, the patient had told the doctor that they had not had one in the past year.

      Now the doctor can have you sign what is called an ABN, Advanced beneficiary Notice. This notice that you would sign states that if Medicare does not pay you will be financially responsible. This way the doctor can bill you if the visit was done within the past year by another doc and Medicare doesn’t pay. Without the ABN signed the doctor cannot bill the patient.

      One other thing to note is that the Annual Wellness Visit is not a routine annual exam. That exam is never covered by Medicare.

      • You can go to your Medicare portal, go to Eligibility, complete the info. Then pick preventative. (At least in CGS). Sort by code, and it will tell you when patient is eligible for whichever preventative code, G0439, etc.

  18. I am having a HORRIBLE TIME billing for medicare GYN exams!!! I dread each call of a patient calling about the balance!!!! Then they call medicare and they just tell the pt we coded it incorrectly to get them off the phone. Then they call us for the 100th time and we explain the same thing and get yelled at.

    I wish medicare would actually explain that the well woman portion 99397 is NOT covered instead of just trying to get them off the phone!!!!

    • Are your providers billing for the G0101 and the Q0091? You are you carving those 2 codes out of the 99397 and billing the patient the balance? Are the providers and/or the front desk telling the patient that a provider will be doing a full physical and only the gynecological exam part of it exam may be covered by Medicare?

      Carolyn Dunn over at Rio Grande Hospital saw your post and emailed me and said:
      “My understanding is that the gyne exam code is G0101, not 99397 which Medicare will not pay for. Gyne exams can only be done every 2 years unless the patient is high risk.”

    • Carol also said:

      “Currently we would bill the G0438 or G0439 and if a gyne exam G0101 only if that hasn’t been done in the past 2 years. We currently do not bill for the Q0091, it’s not in our Charge Master. We have not been billing our Medicare patients the 99397, we only do the annual wellness exam. If we address anything else in addition it is usually and E/M code with modifier 25.”

  19. I am still not getting paid for what I believe KS Medicare says is allowed. I bill G0439(well exam), 99497-33 (rvw health care directive), G0444(screening depression), G0442 (screening for alcohol abuse)Medicare is only paying on G0439 and 99497-33. How do I get G0444 and G0442 paid?

    • SCREENING CODES, (DEPRESSION, FALL) ETC., WILL NEVER GET PAID WHEN YOU BILL THE CLAIM FOR ANNUAL WELLNESS VISIT, WHERE THE SCREENING CODES ARE DEEMED TO BE BUNDLED.

      • You must use modifier XU on those. Be sure you do or Mcare will split the claim then they won’t pay since not included with the G0438/9. The depression screen is included in the wellness and/or G0402.

    • Hello Tarra,

      From my understanding, you should be getting reimbursement for your screenings (G0444, G0442) because you are billing it with G0439. Those screenings are not bundled into subsequent visits, so it is acceptable to use those G codes. My suggestion would be to use a -59 modifier and see if that works. Medicare tends to look for the -59 modifier and will send back claims without it.

  20. What if your patient never had an IPPE as they were already enrolled in MCR when the services started …how do they get their one time only screening EKG? how do we code for that?
    Thanks!

  21. Hi, WE HAVE BEEN BILLING THE G0438 AND G0439 CODE SINCE 2011. THE DOCTORS HAVE FOLLOWED ALL BUT ONE GUIDELINE. IN THEIR PROGRESS NOTE, THE WORD PHYSICAL WAS USED AND NOT THE WORD “WELL VISIT”. THE DOCTORS ACTUALLY DID BOTH BUT DO NOT BILL THE CODE 99397. IF AUDITED, COULD MEDICARE RETRACT PAYMENT FOR THE G0438 OR G0439 DUE TO TERMINOLOGY.

    THANK YOU,

    PAULA CENAC

  22. Can I bill a 99214 instead of the HCPCS code of G0438, G0439 before enrolling a patient into Critical Care Management? Or do they have to be combined?

    • ERIC, 99214 ITSELF IS A LEVEL 4 E&M SERVICE. WHEN YOU DO A ANNUAL WELLNESS VISIT G0438/G0439, A COMPLETE SYSTEM REVIEW IS ALREADY DONE, WHICH TAKES THE PROVIDER ALMOST 45 MINUTES. IN THESE SITUATIONS, THE INSURANCE MAY WANT TO KNOW THE REASON FOR BILLING A LEVEL 4 E&M SERVICE, WHICH AGAIN INVOLVES AT LEAST 40 MINUTES OF PROVIDER TIME. BETTER BILL A LOW LEVEL E&M CODE 99212, ALONG WITH THE WELLNESS SERVICE, AND MENTION THE REASON FOR REFERRING THE PATIENT TO CRITICAL CARE IN THE PATIENT’S CHART.

  23. Can a PCP provide AWV at a patients home? I don’t see that specific POS on the MM7079. He is not home health- just a PCP that provided a home visit and completed the AWV at that time.

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

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

  25. EVERY TIME WE BILL THE G0444 IT ALWAYS COMES BACK DENIED. I KNOW PER MEDICARE IT IS A BILLABLE CODE EVEN WITHOUT MOD 59 IT ALSO IS LINKED TO Z13.89 BUT EVERY CLAIM WE BILLED COMES BACK DENIED.. IT IS BEING BILLED WITH GO439 AND 99214 WITH MOD 25 ON THE OV ANY SUGGESTION ON HOW TO GET G0444 PAID

  26. I am billing G0439, G0444, 99497-33…Medicare is not paying for the G0444, I have tried modifier 25 and 59 on the G0439 but still not working. Medicare customer service is no help..Any ideas on how to get all 3 paid?

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