What Is The Cpt Code For Medicare Wellness Exam
· should be referred to their assigned PCP if a more comprehensive preventive service is warranted. Medicare HMO annual visit CPT code G0402, G0438 and G0439 coverage Medicare Advantage Program Coding for Welcome to Medicare and Annual Wellness Visits
Medicare Billing for Well Woman Exam – Codes G0101 Q0091
· · Medicare Billing for Well Woman Exam – Codes G0101 Q0091 · What Is The Cpt Code For Wellness Exam – ccstem.org CPT G0439 is used to code all subsequent Annual Wellness Visits that occur after the initial Annual Wellness Visit .
Preparing Eligible Medicare Patients For The Awv
Providers can help eligible Medicare patients prepare for their AWV by encouraging them to bring the following information:
- Medical records, including immunization records
- A detailed family health history
- A full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
- A full list of current providers and suppliers involved in their care, including community-based providers and behavioral health specialists
Intensive Behavioral Therapy For Cardiovascular Disease
Also known as a CVD risk reduction visit, this service is essentially cardiovascular risk counseling. Considering heart disease is theleading causeof deathfor men, women, and people of most racial and ethnic groups in the United States, you may not be surprised to learn that this service is often provided with the AWV. Code it as follows:
- Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes
This counseling can be provided annually.
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What Are The 2022 Cpt Codes For Annual Wellness Visits
Medical reimbursements are tied to Current Procedural Terminology codes. They categorize and specify billing rates and rules for procedures, treatments, and care services.
If youre a medical care provider, you likely know this. But do you know the rates and workflows for Medicares wellness programs? Like, Annual Wellness Visits ?
Knowing the billing codes for AWVs will give you a better idea of whats expected, both by the patient and Medicare.
Understanding billing codes will also help you project revenues and optimize your staffs capacity. Without this information, you risk disorganization and a clouded outlook.
At ThoroughCare, weve worked with nearly 600 clinics and physician practices to help them streamline and capture Medicare reimbursements. Our software solution assists with rules and regulations for AWVs, and it tracks all activities related to providing the program, such as conducting patient assessments, making it easier to bill for.
In this article, well briefly review the requirements of AWVs, as well as the programs CPT codes. Well also provide an example return-on-investment of an effective program.
With this information, youll better understand annual wellness billing expectations and standards. Youll also see how care coordination software can simplify the program.
Medicare Preventive Visit The Annual Wellness Visit And Routine Physical Exams: Three Different Services Only Two Are Covered By Medicare
If we see a patient for an Annual Wellness Visit on February 14, 2016, would their next AWV eligible date before February 14, 2017?
Answer:When calculating Annual Wellness Visit eligibility, a full 11 months must pass following the month in which the last AWV was performed. A beneficiary who receives an AWV during a given month, for example, February 14, 2016, will be eligible for their next AWV on the first day of that month in the following year, February 1, 2017 in this example. A full 365 days is not required between Annual Wellness Visits.
When you go to the doctor for a once-a year examination, its important that both you and your doctor know what kind of exam you are there for.
Medicare pays for a one-time Welcome to Medicare preventive visit within the first 12 months you have Part B coverage. During this visit , your doctor will obtain information on your medical and social history related to your health. Social history can mean any history of alcohol, tobacco or other drug use, and your diet and physical activities. Your doctor will measure your blood pressure, weight, height, body mass index, and screen your vision. Your doctor will also give you guidance or advice on preventive services you may wish to consider including certain screenings, shots, and referrals for other care, if needed. You should receive a brief written plan or checklist for the Medicare-covered screenings that you are eligible for.
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Does An Annual Exam Also Include A Well Woman Exam
Yes. The Routine Annual Preventive Physical Exam also includes the components of a Well Woman Exam. If a patient is seen by her primary care physician for an annual, the provider will also include the pelvic and breast exam and a Pap smear collection. If the patient elects to have the Well Woman Exam performed by her gynecologist, the PCP must document that the pelvic and breast exams and pap smear collection were deferred, and will be performed by a gynecologist.
What Should I Bring With Me To The Exam
You should bring the following things with you when you go to your âWelcome to Medicareâ visit:
- Medical records, including immunization records.
- A list of prescription drugs, as well as over-the-counter drugs and supplements that you currently take, how often you take them, and why.
- Family health history. Try to learn as much as you can about your familyâs health history before your appointment.
- Any information you can give your doctor to help determine if you are at risk for certain diseases.
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Alcohol Misuse Screening & Counseling
These are two services that are provided regularly, with the misuse screening almost always performed and the counseling performed when potential misuse is identified. All patients are eligible for alcohol screening patients who are eligible for counseling must screen positive and be competent and alert at the time you deliver the counseling. Code alcohol misuse screening and counseling with the following:
- Annual alcohol misuse screening, 15 minutes
- Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
The screening can be performed annually. For those who screen positive, counseling can be delivered four times per year.
How Can A Clinician Know Which Visit To Bill
They cant, without staff help. Staff can look this up, however.
I suggest using the same template for all three visits.
There are slight variations in the requirements, so develop a template that meets the requirements of both the Welcome to Medicare visit and the wellness visits.
- G0402 requires the testing of visual acuity, and with patient permission, end-of-life planning
- G0438 and G0439 require a list of current medical providers, a health risk assessment, and an assessment of cognitive function. The content of the health risk assessment is usually in the screening for the Welcome to Medicare visit.
This allows you to bill any one of the three visits based on the documentation.
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Whats Included In A Medicare Wellness Visit
A Medicare Wellness Visit, also called a wellness exam, is an assessment of your overall health and well-being. The primary purpose is prevention either to develop or update your personalized prevention plan. Medicare covers a Wellness Visit once every 12 months , and you are eligible for this benefit after you have had Part B for at least 12 months.
During the exam, your primary care provider combines information from the visit with your medical record to gauge your risk for common preventable health problems such as heart disease, cancer and type 2 diabetes. Based on whats learned, your doctor creates your personal prevention plan with a checklist of screenings you need to have.
The list below shows some of the things your doctor may do during a wellness exam.
- Develop a screening schedule for the preventive services recommended for you
Medicare Part B covers an annual wellness exam and many preventive screenings with no copay or deductible. However, you may have to pay a share of the cost for certain recommended tests or services. And while its not mandatory, there are very good reasons to have a wellness exam every year.
Three Unique Codes: G0402 G0438 And G0439
Medicare preventive wellness visits fall into three categories the Welcome to Medicare Visit, also known as the Initial Preventive Physical Exam , the initial Annual Wellness Visit, and subsequent Annual Wellness Visits. Each has its own Current Procedural Terminology code that must be used in the right circumstances and proper order.
During the first twelve months a patient is enrolled in Medicare, they are eligible for the Welcome to Medicare Visit. This is a one-time visit that includes vital measurements, a vision screening, depression screening, and other assessments that are meant to gauge the health and safety of an individual patient. This visit must be coded using CPT G0402. Once a patient has been enrolled for more than twelve months, the G0402 code will be rejected regardless of whether the IPPE visit previously took place or not.
After a patient has been enrolled in Medicare for twelve months, they become eligible for an Annual Wellness Visit. If they completed an IPPE, the patient is eligible for the initial AWV on the first day of the same calendar month the following year. An AWV is similar to the IPPE but includes slightly different required and accepted screenings. This initial AWV must be coded using G0438.
Incorrect Coding Equals Lost Revenue
The mistake he was making that was costing him money is the same mistake I saw recently in a large primary care group. It was billing a subsequent annual wellness visit when the patient was eligible for an initial annual wellness visit.
The physician, like the group I visited recently, billed the Welcome to Medicare visit in the first year the patient was enrolled in Medicare and then billed a subsequent wellness visit the next year. They missed the initial annual wellness visit.
The correct sequence is:
- First, bill the Welcome to Medicare visit. The patient is eligible for this service within the first year of enrollment with Medicare.
- Second, bill the initial annual wellness visit. The patient is eligible for this after 11 full months have passed since the Welcome to Medicare visit, or if they didnt have the Welcome to Medicare visit in the first full year of enrollment.
- Third, bill the subsequent annual wellness visit .
Why does it make such a big difference?
The payment for the initial annual wellness visit is much higher than the payment for the subsequent wellness visit.
Run a CPT® frequency report
My first suspicion that the group was billing these incorrectly was when I looked at the volume for these three visits. There werent many initial annual wellness visits.
If you are wondering if the primary care clinicians in your group and the coders understand this, run a frequency report that shows the number of times these three codes were billed.
The Value Of Medicare Wellness Visits
The main benefit of the AWV to patients is the creation of a personalized prevention plan, a written plan that can help guide their preventive care decisions for the next five to 10 years. This plan includes age-appropriate preventive services, recommendations offered by both the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices, and personalized health advice that identifies risk factors and suggests referrals or programs to address them.3
Providing Medicare wellness visits also offers a structure that helps physicians to close many pay-for-performance quality measure gaps, including those recognized by the Core Quality Measures Collaborative, the Integrated Healthcare Associations California Value Based P4P program, and the National Committee for Quality Assurances Healthcare Effectiveness Data and Information Set. In addition, accountable care organizations participating in the Medicare Shared Savings Program can use data collected during wellness visits to satisfy specific quality measures for the 2018 and 2019 quality reporting years.4
Counseling To Prevent Tobacco Use
If patients use tobacco regardless of whether they exhibit signs or symptoms of tobacco-related disease they are eligible to receive tobacco cessation counseling. Code this counseling with the following:
- Smoking and tobacco use cessation counseling visit intermediate, greater than 3 minutes up to 10 minutes
- Smoking and tobacco use cessation counseling visit intensive, greater than 10 minutes
Medicare will cover two cessation attempts per year, with each attempt including a maximum of four intermediate or intensive sessions, with the patient receiving up to eight sessions annually.
How To Avoid Medicare Annual Wellness Visit Denials
If youre seeing a high number of denials for Medicare annual wellness visits , youre not alone. Identifying whether to code for an Initial Preventive Physical Exam , an initial Medicare AWV, or a subsequent Medicare AWV can be tricky.
Common reasons for denial include the folllowing:
1. Billing a G0438 or G0439 when the patient has been enrolled in Medicare Part B for 12 months or less. This situation instead calls for billing G0402 .
2. Billing for a Medicare AWV when the patient only has Medicare Part A. They must have Part B coverage as well.
3. Using the wrong primary diagnosis code. If the primary diagnosis code is problem-oriented , Medicare will most likely deny a claim for an AWV, because AWVs are well visits. Instead, list a well code as the primary diagnosis.
The IPPE also has a slightly different set of required components than the two types of AWVs .
Here are some frequently asked questions to help you further navigate the world of AWV billing, as well as a side-by-side comparison of the three types of Medicare wellness visits.
Q – What is the difference between a Medicare AWV and a preventive visit?
Q – Can a Medicare patient receive a preventive visit?
Q – Is the IPPE the same as the initial AWV?
Q – What diagnosis code should I use to bill a Medicare wellness exam?
A – Use the Z00 family of codes.
Q – Do Medicare wellness visits need to be performed 365 days apart?
Q – Can I perform a pap smear or pelvic exam during a Medicare AWV?
Basics Of Hcpcs Code G0402 G0438 & G0439
The Annual Wellness Visit is a free annual preventive visit which focuses on providing a personalized prevention plan of services for Medicare Advantage members. The AWV is not a routine physical exam. AWV can be performed by Physician , qualified non-physician practitioner or medical professional , or a team of medical professionals working under the direct supervision of a physician may perform the AWV. However, for Risk Adjustment purposes the AWV must be completed by a CMS approved provider. HCPCS code G0438 & G0439 are used for reporting Annual Wellness Visit .
Initial AWV is available to the beneficiary during the second year of eligibility for Medicare. Subsequent AWV are allowed once per calendar year after the initial AWV
E/M service may be billed in addition to the AWV. Report the Current Procedural Terminology code with modifier -25.
Medicares Annual Wellness Visit
The Medicare Annual Wellness Visit is a yearly appointment with a health professional to identify health risks and help reduce them and to create or update a personalized prevention plan. During a Medicare AWV, health professionals should also review any current opioid prescriptions, detect any cognitive impairment, and establish or update medical and family history.
Check Your Macs Website
Office staff can check their Medicare Administrative Contractors website to determine which visit the patient is eligible for. Or, the CMS site above.
While it is true that this takes time to do and can be difficult in a busy practice, it saves the time of resubmitting claims that were denied.
Dont miss billing the Initial Annual Wellness Visit!
CMS updated the MLN Matters article in October of 2020. You can find it l.
Annual Wellness Visit Health Risk Assessment
The AWV includes a HRA. See summary below of the minimum elements in the HRA. Get more information in the CDCs A Framework for Patient-Centered Health Risk Assessments booklet, including:
- Evidence suggests HRA use and follow-up interventions can positively influence health behaviors
- Definition of the HRA framework and rationale for its use
- Guidance on HRA use, reduction of health disparities, and improving health outcomes through identifying modifiable health risks and providing behavior change interventions
- Sample HRA
Perform Health Risk Assessment
- Get patient self-reported information
- You or the patient complete the HRA before or during the AWV it shouldnt take more than 20 minutes
1.Establish patients medical and family history
At a minimum, document:
2.Establish list of current providers and suppliers
12. Screen for potential Substance Use Disorders
1. Review and update Health Risk Assessment
Annual Preventive And Wellness Visit Service
Preventive Service Codes
- Initial Visits – 99381, 99382, 99383, 99384, 99385, 99386, 99387
- Subsequent Visits – 99391, 99392, 99393, 99394, 99395, 99396, 99397
- Welcome to Medicare – G0402
- Initial Annual Wellness Visit – G0438
- Subsequent Annual Wellness Visit – G0439
- 99381 – Infant
- 99382 – Early childhood
- 99383 – Late childhood
- 99384 – Adolescent
- 99385 – 18-39 years
- 99387 – 65 years and older
- 99391 – Infant
- 99392 – Early childhood
- 99393 – Late childhood
- 99394 – Adolescent
- 99395 – 18-39 years
- 99397 – 65 years and older
- List of current medical providers
- Height, weight, BMI, BP, and other appropriate routine measurements
- Detection of cognitive impairment
- Review risk factors Review of functional ability
- Establish a written screening schedule for the next 5-10 years
- Establish a list of risk factors
- Provide advice and referrals to health education and preventative counseling services