Coding Medicare Annual Wellness Visits Along with a 99397

March 29, 2018
Bill Dacey

Coding expert explains why we don't typically see a 99397 and an AWV, and why Medicare discourages this from happening.

Q: To bill a 99397 along with a Medicare Annual Wellness Visit, do I have to document how much time I spent with a patient on this topic?

A:  No, neither of these codes has any time component to them whatsoever - so that will not be of any use. A larger answer to your question is that we don’t usually see a 99397 and an AWV. Medicare does discourage this and says there is too much ‘crossover’ between these two preventive services.

We usually see a 99213 or 99214 with a G0438 or G0439 to represent the problem management outside the AWV. If you bill G0438/G0439 and a 99397, recognize that Medicare does not cover the 99397. Some Medicare secondary payers will, but you’d better have pretty good knowledge of the patient’s payer type or else you are consigning them to a pretty big bill, likely a lot too for the screening labs that could go with it.

All that said, if you bill both of these codes, you’d better label each section precisely and say what you are doing in the chief complaint (i.e. Here for Medicare Annual Wellness visit and Annual Physical Exam/ Health Maintenance). Be sure you have all the AWV elements under that heading, and do a decent life-cycle commentary, review of systems, patient family and/or social history, and comprehensive exam. It needs to look like two very distinct things.

Q:  If we do a pap/pelvic/breast exam during a physical exam (99395, 99396, etc.) should I be billing separately for that? On my current billing sheet, there is a G0101 for Medicare patients and a Q0091 for pap.  Should I be circling the second one for a non Medicare patients (since we don’t typically do pap tests on Medicare patients unless there is a problem)?Are there any RVUs attached to these G-codes? If I do the pap on a separate day from the physical exam would I code something differently?

A:  The commercial Health Maintenance visit codes (99381-99397) include a pelvic and breast exam. It is assuredly part of the 'age and gender appropriate' physical exam.

Medicare, which doesn't pay for the above codes, recognizes the G0101, Q0091 as their AWV visits. The G0439, etc. does not include a physical - and so these female wellness ‘carve-outs’ are payable. But as you say - you won't do many of these on these patients, unless there is an issue - and that’s not pure screening.

Where we cannot give certain infallible guidance is on the variety of Medicare Advantage plans - we have to say only that if they pay 99381-99397 they probably don't want a G0101 with it. But there can easily be exceptions to that.

And yes, the G0101 Pelvic/Breast Exam has .45 RVUs, and the Q0091 - obtaining pap has .37. The pap on a day different than the exam can be a long conversation. As a primary-care, you might get these in several ways:

1. In a follow-up to an annual where for some reason the pap couldn’t be completed the first time – in which case the payer could rightly expect that you were just ‘finishing’ the annual that you already billed them for.
2. If you are female provider, you end up doing a pelvic separately because the male provider that did the annual directs the pelvic portion of a female exam to you as a practice protocol. Again, the payer may not recognize that there was medical necessity for another visit, beyond the first one, where they had already paid for a complete annual.
This could be made even more complex if the other provider is in another group. If you have a diagnosis, then again these are not purely screening and should be adjudicated based on the payers billing policies.
What you do not want to do is to bill pelvics and/or paps apart from an annual, which are really integral to the overall screening exam, and ‘find’ a diagnosis to get these paid.