You schedule a patient's first Medicare annual wellness visit (AWV). The patient comes into your organization, or perhaps you meet via telehealth. You furnish the AWV, seemingly checking all the boxes necessary to deliver this critical yearly appointment that helps prevent illness and get your organization paid. And yet a few weeks after submitting your claim to Medicare for the service, it's denied.
The reason: You incorrectly used HCPCS code G0438.
Denials can lead to increased days in accounts receivable, write-off rates, and overall cost to collect, among other headaches. A study revealed that many AWVs conducted and billed may fail to meet compliance requirements set forth by CMS, which can trigger denials or more serious ramifications. If you want to better ensure that your annual wellness visit claims are not denied, you must know how to properly code them.
In this piece, we provide you with the HCPCS codes you need to use for annual wellness visits. We also share guidance that should help reduce the likelihood that your organization will experience denials associated with this service and another service commonly associated with the AWV that may trip you up: the initial preventive physician examination (IPPE).
What Is G0438?
G0438 is the HCPCS code you should use when coding a patient's first annual wellness visit. Its long descriptor is "Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit," while its short descriptor is "Annual wellness first."
Two key things to know about HCPCS G0438:
- It can only be used for a Medicare beneficiary who is no longer within the first 12 months after the effective date of their Part B coverage; and
- It can only be used for a Medicare beneficiary if they have not already received either an initial preventive physician examination (discussed further below) or an annual wellness visit within the past 12 months.
Medicare pays for a single initial AWV per beneficiary per lifetime. Note: For help identifying patients eligible for the annual wellness visit, download this helpful guide.
What Is G0439?
G0439 is the HCPCS code you should use for all subsequent annual wellness visits. Its long descriptor is "Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit," while its short descriptor is "Annual wellness subseq."
An important caveat: If your organization takes on a new Medicare beneficiary and is providing its first annual wellness visit to a patient, you must determine whether the beneficiary had an initial AWV furnished by another organization. If that's the case, you would use HCPCS G0439 rather than HCPCS G0438 since G0438 was already billed for by the other organization.
Some companies — like Prevounce — have the capability to determine patients’ annual wellness visit eligibility by checking Medicare claims data. Partnering with such a vendor can help ensure your organization consistently furnishes, codes, and bills for the appropriate AWV.
Note: If you're looking for help establishing or growing an existing AWV program, watch this on-demand webinar. What Is G0402?
Now let's discuss the initial preventive physician examination. Misunderstanding of the IPPE and how to code it can also lead to denials.
Broadly speaking, IPPE, also known as the "Welcome to Medicare" visit, is a review of a Medicare beneficiary's medical and social health history coupled with education on preventive services. Medicare pays for a single beneficiary IPPE per lifetime, and it must be furnished no later than the first 12 months after the beneficiary's eligibility date for Medicare Part B benefits.
G0402 is the HCPCS code you should use for the IPPE. Its long descriptor is "Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment," while its short descriptor is "Initial preventive exam."
Common Denials Associated With Misuse of G0438 and G0439
If you misuse HCPCS G0438 or HCPCS G0439, it will likely trigger a denial. Here are a few typical ways that practices incorrectly code annual wellness visits:
- If you submit G0438 for a Medicare beneficiary for whom a claim with code G0438 has already been paid, your claim will be denied with a claim adjustment reason code (CARC) of 149 ("Lifetime benefit maximum has been reached for the service/benefit category.") and a remittance advice remarks code (RARC) of N117 ("This service is paid only once in a patient's lifetime.").
- If you submit a claim for a G0438 or G0439 within the first 12 months after the effective date of the beneficiary's first Medicare Part B coverage, it will be denied as that beneficiary is eligible for the IPPE. Such claims will be denied with a CARC of 26 ("Expenses incurred prior to coverage.") and a RARC of N130 ("Consult plan benefit documents/guidelines for information about restrictions for this service.").
- Do not bill G0438 or G0439 within 12 months of a previous billing of a G0402 (initial preventive physician examination), G0438, or G0439 for the same beneficiary. These subsequent claims will be denied with a CARC of 119 ("Benefit maximum for this time period or occurrence has been reached.") and the aforementioned N130 RARC.
Note: Patients are eligible to receive Medicare annual services again on the first of the month they are performed in, one year later. For example, if a patient has an AWV on Nov. 20, 2020, they are eligible again on Nov. 1, 2021.
Additional Annual Wellness Visit Coding Tips
When patients receive their annual wellness visit, it is often accompanied by one or more evaluation and management (E&M) services. If you provide what can be defined as a "significant, separately identifiable medically necessary E&M service" in addition to the annual wellness visit, CPT codes 99201-99215 may be reported. Along with HCPCS G0438 or HCPCS G0439, CPT code modifier -25 must be appended to the medically necessary E&M service. CPT guidelines define the -25 modifier as "Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service."
Before coding and billing for one or more E&M services, determine whether some of the components of the medically necessary E&M service, such as a portion of the history exam, were part of the annual wellness visit. If that's the case, these components should not be included when determining the most appropriate level of the billable E&M service.
If you've been researching how to code and bill for the annual wellness visit, you may have seen HCPCS code G0468. Unless you work in a federally qualified health center (FQHC), this HCPCS code would not apply. G0468 is used by FQHCs to code and bill for AWVs and IPPEs. Its long descriptor is "Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV," while its short descriptor is "FQHC visit, IPPE or AWV."
Finally, it's important to understand that when you furnish the annual wellness visit, many Medicare Part B preventive services may be provided as optional elements. Such services can include advance care planning, depression screening, alcohol misuse screen and counseling, and counseling to prevent tobacco use.
Want to learn more about providing and getting paid for preventive services? Check out our detailed guide!
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Health economic and reimbursement information provided by Prevounce is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules, and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice.
Prevounce encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services rendered. It is also always the provider’s responsibility to understand and comply with Medicare national coverage determinations (NCD), Medicare local coverage determinations (LCD), and any other coverage requirements established by relevant payers which can be updated frequently.
Prevounce recommends that you consult with your payers, reimbursement specialists, and/or legal counsel regarding coding, coverage, and reimbursement matters.
Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements.
The coding options listed here are commonly used codes and are not intended to be an all- inclusive list. We recommend consulting your relevant manuals for appropriate coding options.
The Health Care Provider (HCP) is solely responsible for selecting the site of service and treatment modalities appropriate for the patient based on medically appropriate needs of that patient and the independent medical judgement of the HCP.