Coding for wellness visits and time-based statements

October 22, 2018

This month’s coding questions look at how timing plays a role with annual checkups and the stipulations that must be met for coding by time.

Q: If a patient had an annual wellness visit Nov. 15, 2017, can the patient be seen again Nov. 3, 2018?

A: There are really two answers to this. When these codes were enacted in 2011, Medicare clarified the exact timeframe between visits:

“Annual wellness visits (AWVs) are covered by Medicare at 12-month intervals. This means that 11 full calendar months must pass after the month in which a beneficiary had received an AWV. Under this method of counting, a beneficiary could receive an AWV at the end of a given month, for example, January 2011, then in the following January 2012, the beneficiary would be eligible for an AWV in the beginning of that month. Therefore, 365 days would not need to elapse between visits, provided that 11 full months had passed since the last visit.”

So, with that in mind your Nov. 3, 2018, G0439 would be covered.

However, depending on your location, Medicare has been known to deny a subsequent AWV before the 365th or 366th day between them.  You need to find the specific regulation or payment policy that your Medicare administrative contractor (MAC) follows.


Q: I was told that the time-based statement I put in every inpatient note is not acceptable because I had too much information in it. How is that possible? Every one of these references 25 minutes total time, which includes the history, exam, discussion with nursing staff, and counseling. Can you see a problem with this?

A: It sounds like you might be saying you spent 25 minutes doing all of this, which is not the formula for coding by time. Providers have the option to code by time in certain circumstances. Per the CPT manual, history, exam, and medical decision making are considered the key components of a visit. Those service descriptors, not time, are usually used to select the level of code. You are supposed to use time to select a code only when counseling or coordination of care accounts for more than 50 percent of the time spent with the patient.

From your question, it sounds like you do this every time. That may be a problem if those circumstances don’t exist every time.

Maybe the bigger problem is the inclusion of all visit components: interviewing the patient (history), physical exam, counseling, and discussion of the case with the team. You can’t comingle the Hx/MSE/MDM part with the counseling/coordination part, as that would render the whole statement useless. You must also make it clear that over half of that time is spent in either counseling or coordination or care.

When it is appropriate to code by time, the best way to document this is to indicate that you “Spent over half of ___ minutes counseling the patient on ____.” You can also substitute “coordinating care” for counseling. In either case, Medicare requires that you detail the content of that counseling or coordination of care. Again, from the information above, it is not clear whether you documented that “over half of” or “most of” part of the statement.

If the new Medicare proposed documentation reduction goes into effect, this should become less of a burden. But you still need to ensure that you’re noting what the rules call for.

Bill Dacey, MHA/MBA, CPCis principal in The Dacey Group, Inc., a consulting firm dedicated to coding, billing, documentation, and compliance concerns for physicians. Dacey is a AAPC-certified coding instructor and has been active in physician training for more than 25 years. He can be reached at