What diagnosis code do you use for the Medicare's Welcome to Medicare Physical? V70.0 is denied. And if V70.0 is denied by Medicare what other code do we use for other physicals?
Medicare's New Annual Wellness Visit
Medicare's New Annual Wellness Visit
Conference Report, Pearl | January 12, 2011 | Pearls, Billing Compliance, Coding, Denials, Healthcare Reform, Medical Billing & Collections, RVU
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(If you want more information on the Medicare Annual Wellness Exam, watch our 4-minute "Video Primer" here.)
"I'm calling to schedule that new Medicare physical I heard about on the news today." Sound familiar? This is what primary-care practices are now hearing and since only a few weeks separated the release of the Physician Fee Schedule Final Rule and the implementation on January 1, 2011, physician practices have been scrambling to get ready.
The Patient Protection and Affordable Care Act of 2010 added a new benefit for Medicare recipients called an Annual Wellness Visit. Contrary to patient and physician expectations, it is not a physical exam or preventive medicine service, as defined by CPT codes 99381-99397. In fact, those services remain noncovered and if billed they will be denied as routine by Medicare.
The initial Annual Wellness Visit has more in common with the unpopular Welcome to Medicare Visit, also called the Initial Preventive Physical Examination. Patients who are newly enrolled in Medicare are still — and only — eligible for the Welcome to Medicare Visit in the first year of their Medicare enrollment.
A patient is eligible for the initial wellness visit if she has been enrolled in Medicare for longer than 12 months and has not received a Welcome to Medicare visit in the past 12 months. Let's say a patient enrolls in Medicare on July 1, 2010. She is eligible for a Welcome to Medicare visit from July 1, 2010 until June 30, 2011. She schedules her visit on May 5, 2011. She will then be eligible for her first wellness visit after May 6, 2012 — one year after the Welcome to Medicare visit.
A different patient, however, enrolled in Medicare February 1, 2008. On January 1, 2011, he became eligible for the initial wellness visit. He calls immediately and is scheduled for February 5, 2011 for his initial visit.
This visit requires:
• Taking or updating his medical and family history;
• Establishing a list of current providers and suppliers of medical care;
• Height, weight, BMI calculation (or waist circumference), blood pressure, and "other routine measurements as deemed appropriate";
• Detection of any cognitive impairment that he may have by direct observation, with consideration of information from medical records, patient reports, concerns raised by family members;
• Review for the potential for depression based on use of an appropriate screening instrument;
• Review of his functional ability and level of safety, based on direct observation, or use of a screening questionnaire;
• Establishment of a written screening schedule, such as a checklist, for the next 5-10 years based on recommendations of the US Preventive Task Force and Advisory Committee on Immunization Practices, and the patient's health status, screening history, and age-appropriate covered Medicare services;
• Development of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway — including mental health conditions or risk factors, or conditions identified through an previously performed Welcome to Medicare Visit (or this visit), and a list of treatment options and their associated risks and benefits; and
• Furnishing of personalized health advice and referral, as appropriate, to health education or preventive counseling programs aimed at reducing identified risk and improving self management — including weight loss, smoking cessation, fall prevention, and nutrition.
(End of life planning was removed as a requirement.)
What's the code for the service? G0438: Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit.
The visit has 4.74 Relative Value Units, for a national payment of $159.25.
If you want more information on the Medicare Annual Wellness Exam, watch our 4-minute "Video Primer" here.
Betsy Nicoletti is the founder of Codapedia.com. She is the author of "A Field Guide to Physician Coding." She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at betsy.nicoletti@gmail.com.
*Seniors and doctors alike are hot for the highly publicized new wellness visit under Medicare, but a story about claim denials from contractors is apparently causing a bit of alarm. Read, "Watch Out for Medicare Wellness Visit Glitches" to find out the details.
The article said -pt is eligible for her first wellness visit 1 yr after the initial welcome to medicare visit .Does that mean that medicare will cover preventive physical codes 99381-99389 at the wellness visit?
Can this Annual Wellness Visit be done for Nursing Home patients in addition to their routine annual H&P visit?
I understand that regular Medicare does not pay for a "Physical Exam". Does it matter if patients have Medicare Advantage Plans? I have been under the impression that original Medicare and Medicare advantage do not cover CPT 99381-99397. Is this correct? Thanks.
Yes, you can bill both a G0438 and a 99213 or 99214 with the visit.
Medicare says that no part of the documentation used for the G0348 (the wellness visit) may be used to select the level of service for the problem oriented visit. That means, none of the PFSH can be used to select your level of code. There is not much exam required for the wellness visit (vitals) so you can use the exam in code selection. For MDM, giving the patient a list of their conditions and your recommendations is part of the AWV. So, for code selection for the problem oriented visit, I would expect to see an acute problem treated or a change in the status of their chronic conditions, to differentiate it from the work of the wellness visit. I must emphasize that this is how I interpret CMS's remarks not to use the documentation from the wellness visit to select your E/M. This is my opinion about how to operationalize that statement.
Medicare says that no part of the documentation used for the G0348 (the wellness visit) may be used to select the level of service for the problem oriented visit. That means, none of the PFSH can be used to select your level of code. There is not much exam required for the wellness visit (vitals) so you can use the exam in code selection. For MDM, giving the patient a list of their conditions and your recommendations is part of the AWV. So, for code selection for the problem oriented visit, I would expect to see an acute problem treated or a change in the status of their chronic conditions, to differentiate it from the work of the wellness visit. I must emphasize that this is how I interpret CMS's remarks not to use the documentation from the wellness visit to select your E/M. This is my opinion about how to operationalize that statement.
Medicare Advantage plans have most frequently covered what we think of as a "typical" or normal preventive service, as described by the 9939X codes, while fee-for-service Medicare has not. For each Medicare Advantage plan, you have to find out what the patient's coverage is and what that plan covers. They could still recognize preventive medicine services or they could have switched to the wellness visits. There's no definitive answer to this question.
As to the earlier question: V70.0 is a payable diagnosis code for the wellness visits. Are you sure it is all linked correctly? I'd call the Contractor.
As to the earlier question: V70.0 is a payable diagnosis code for the wellness visits. Are you sure it is all linked correctly? I'd call the Contractor.
I was wondering I billed our welcome to medicare exam with the appropriate IPPE code but the diagnosis was V70.0 and it was denied as routine so how do we code these type or IIPE exams to get paid?? Please help I feel like I am a detective trying to find out the answer. Also the Annual Wellness exam if you code that V70.0 same issue. is there a special Medicare Procedure code to bill for that like the IPPE exam or do I use a Wellness Exam code and how do we know that it wont be denied as a Routine exam which we know they wont pay. Please help I am holding claims til I can figure this out, to bill correctly the first time...thanks so much:)
Question what do we bill the Annual Wellness Physical code???? What procedure code and diagnosis code do we use without it being denied by medicare as routine? Also for the IPPE exam what diagnosis do you use as the V70.0 gets denied as routine.
I know you are talking about adult population.
How about pediatrics- do we continue to schedule well child exams? or should we change the name to wellness visits?
How about pediatrics- do we continue to schedule well child exams? or should we change the name to wellness visits?
What has to be done if this exam is performed by an OB/GYN physician? Are they required to do all of the exam in order to receive credit? Since they are setting up a plan, do they have to follow the patient or can that be done with their primary care physician? Are their guidelines for these situations?
Thank you.
Is there a specific diagnosis code that needs to be used? If there is a separate problem which is billed with the E&M code, how does Medicare know that diagnosis is related to the E&M code and not the Wellness visit?
Hi - My name is Bill Dacey. I'm one of the contributors for the Coding Question section. I was asked to address Chiyang Wu's question about physical exams. You specified 'Physical Exam' in your comment. I assume you are referencing the fact that teh Medicare AWV services clearly don't include an exam. This is true as Betsy's column points out. However, it has been my experience in the last couple of years that most MDs are coming around to the notion that an AWV billed along with a problem oriented EM is good to accomplish a couple of things. First, remember that for years providers have been in effect 'giving away' the overall preventive service. You;ve been doing them along with chronic disease follow-up visits, and years ago billing the combined service a 99215 which was pretty obviously a work-around. Still, often two services were provided, and only one billed. Now you can do whatever disease management is needed, take a comprehensive history update, including the assesssment of impairment and risk factors and the other odd bits of the AWV, perfrom your comprehensive exam - and at the end of the day, you've done a 'CPE' and and EM - get paid for both and do what needed to be done. But yes, to your point the 'physical exam' is not specifically covered, but it never has been. As to the Advantage Plans- most of them pay for both the AWV and an EM together, some may not. No Medicare plan pays for the 99381-99397 codes that I am aware of. Hope that helps.
Isn't the G0438 for new patients and the Code G0439 is the one to use for established patients? Will we be able to also bill for an office visit with a 25 for other things ... as example like a sore throat.
So, based on this "Now you can do whatever disease management is needed, take a comprehensive history update, including the assesssment of impairment and risk factors and the other odd bits of the AWV, perfrom your comprehensive exam - and at the end of the day, you've done a 'CPE' and and EM - get paid for both and do what needed to be done."
How should we bill for both services? Can we combine a G0438 with 99213,99214?
How should we bill for both services? Can we combine a G0438 with 99213,99214?
Medicare will not cover 99381-99397. The Welcome to Medicare visit is billed with code G0402. A patient is eligible for the Welcome to Medicare visit in the first year of their enrollment on Medicare.
They are eligible for the Initial Annual Wellness Visit if they have been on Medicare for over one year, of one year after the Welcome to Medicare.
99381--99397 remain non-covered services.
They are eligible for the Initial Annual Wellness Visit if they have been on Medicare for over one year, of one year after the Welcome to Medicare.
99381--99397 remain non-covered services.
Neither the initial Annual Wellness exam (G0438) nor the subsequent Annual Wellness exam (G0439) are defined as new or established patients. A patient is eligible for the Initial AWV this year if they have been on Medicare for over one year, and have not received the Welcome to Medicare visit in the last year. They are eligible for the subsequent Annual Wellness Visit one year after the Initial Annual Wellness Visit.
Medicare said that it doesn't expect that a clinician would routinely bill for both the Wellness Visit and a problem oriented E/M code. If both are done, you may not use any of the documentation from the Wellness Visit to select the level of E/M service. CMS suggests that you schedule problem oriented visits separately from the Wellness Visit.
There are no specifically required diagnosis codes for the Annual Wellness Visits, according to the transmittal. There are some reports in the press that these visits are being denied with V70.0, but it appears to be a Contractor error. I suggest using V70.0.
Hello,
My name is Beverly and I work for a Family Practice , we are new at billing the Medicare AWV. Do your have to be a minimum of 65 years of age to receive this wellness exam?
My name is Beverly and I work for a Family Practice , we are new at billing the Medicare AWV. Do your have to be a minimum of 65 years of age to receive this wellness exam?
No. Age is not a factor for the Wellness Visits.
The patient is eligible for the Welcome to Medicare Visit in the first year of enrollment to Medicare, at whatever age the patient enrolls. Typically, that is 65 but some patients who are disabled are eligible for Medicare at a younger age.
The patient is eligible for the initial AWV one year after they receive the Welcome to Medicare Visit, or if they have been on Medicare for longer than year. This visit may be performed for new or established patients. The patient is eligible for the subsequent AWV one year after the initial AWV.
The patient is eligible for the Welcome to Medicare Visit in the first year of enrollment to Medicare, at whatever age the patient enrolls. Typically, that is 65 but some patients who are disabled are eligible for Medicare at a younger age.
The patient is eligible for the initial AWV one year after they receive the Welcome to Medicare Visit, or if they have been on Medicare for longer than year. This visit may be performed for new or established patients. The patient is eligible for the subsequent AWV one year after the initial AWV.