The importance of utilizing preventive medicine to improve the health and ultimately lives of patients is widely recognized. However, for this potential to be reached, medical practices must be able to provide preventive care services in a financially sustainable way. We’ll share more about this later in the article.
One piece of the process toward making preventive services viable is for medical practices to complete the Medicare Annual Wellness Visit reimbursement coding process accurately. Doing so will not only ensure that practices receive their earned reimbursements, but it will also protect them against the possible penalties that they might incur from failed coding audits.
While this is by no means a comprehensive guide to Medicare Annual Wellness Visit reimbursement, we would like to offer medical practices the following information to assist them in avoiding some of the most common coding mistakes that result in rejected claims, lost revenue, or failed audits.
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 (IPPE), 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.
CPT G0439 is used to code all subsequent Annual Wellness Visits that occur after the initial Annual Wellness Visit (G0438). So, if used correctly, G0439 would not be used until G0402 was used to code the IPPE, and G0438 was used to code the initial AWV. In the case that an IPPE was never completed, G0439 would still be used for any subsequent visits after G0438.
Though G0402, G0438, and G0439 are commonly confused, the reason for needing three separate codes is pretty straightforward. It is assumed that the different types of visits take different amounts of resources, and so they are reimbursed at different rates.
For example, the initial AWV is used to collect the library of information that will be continually updated with each subsequent Annual Wellness Visit. As a result, the G0438 code is reimbursed at a rate that is nearly 50% higher than G0439. So if a medical practice regularly misses using the G0438 code for an initial Medicare Annual Wellness Visit and uses G0439 instead, it could mean a significant loss of revenue.
In addition to the primary visit codes (G0402, G0438, and G0439), a select list of other codes may be billed for services performed during a Welcome to Medicare Visit or Annual Wellness Visit. When using any of these codes, a separate note is required to support each rendered service.
It is important to note that many of these codes have specific guidelines that require them only to be used with specific visits after meeting certain criteria. For example, CPT G0444, which designates a fifteen-minute annual depression screening, may only be included with subsequent wellness visits that are billed under G0439. If that specific code is used with the IPPE or initial AWV, it will be rejected as invalid. An Abdominal Aortic Aneurysm (AAA) screening, coded as G0389, may only be performed with the IPPE code G0402 - it is not approved for Annual Wellness Visits.
Advance Care Planning (99497) is considered an optional element of the Annual Wellness Visit, which includes a discussion with the patient about their advance care wishes and advance directive. Advance Care Planning is considered a preventive service (and thus has its co-pay waived) when billed on the same day as an Annual Wellness Visit with modifier 33.
G0442 and G0443 are additional codes that must be used in conjunction with each other to be valid. G0442 is used for an Annual Alcohol Screening, which should take approximately fifteen minutes. G0443 is for fifteen-minute sessions of alcohol counseling. According to The Centers for Medicare & Medicaid Services, the screening service must take place before a counseling service is approved. In other words, if G0443 is used, and there are no claims for G0442 in the preceding twelve months, the screening code will be denied.
Fifteen-minute obesity counseling sessions may be billed in conjunction with IPPE visits or Annual Wellness Visits using CPT G0447. This service includes dietary assessments and behavioral counseling, but a patient must have a body mass index of thirty or above to qualify.
If you ever have a wellness visit that takes a particularly long time, there is also a set of add-on codes you can use. G0513 and G0514 are 'prolonged preventive service codes' that can be used when a service takes 30 minutes (G0513) or 60+ minutes (G0514) past the typical duration of the service.
Staying Up to Date
To avoid risking an audit, it is essential to stay up to date on coding requirements associated with Medicare Annual Wellness Visits, as they are revised on occasion. For example, older documentation states that G0436 Smoking Cessation Counseling (3-10min) and G0437 Smoking Cessation Counseling (10-20min) is approved for coding with wellness visits; however, as of 2016, these codes have been replaced with 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes). This sort of coding replacement is relatively common, and utilizing the old codes will lead to denied claims.
With changing guidelines and particular eligibility requirements, the task of coding correctly to maximize revenue on preventive health visits can be daunting for medical office staff. But without the necessary revenue, practices are unable to support the practice of preventive health services, which could negatively impact the care given to patients.
Providing Preventive Care in a Financially Sustainable Way
For this potential to be reached, practices must be able to provide preventive care services in a financially sustainable way while remaining vigilant to coding and policy changes.
Many offices struggle to remain compliant with the dynamic nature of Medicare bureaucracy, particularly because the majority of their time and focus is on patient care as opposed to monitoring regulation fluctuations.
Prevounce focuses on making preventive wellness work for everyone, from patients to providers and everyone in-between. We lift the burden of sorting through Medicare regulations to help you understand how preventive services can be utilized to best benefit the patient and your practice.