Monday, January 26, 2015

Wellness visit CPT codes G0402, G0438, G0439 - Medicare welcome


Annual Wellness Visit (AWV) HCPCS/CPT Codes


G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment

G0403 Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

G0404 Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

G0405 Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Code G0402 must be used to report the IPPE. The various components of the IPPE previously described on slide 6 must be provided and documented in a beneficiary’s medical record during the IPPE.


Billing Requirements : 

Two new HCPCS codes, G0438 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit, (Short descriptor – Annual wellness first) and G0439 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit, (Short descriptor – Annual wellness subseq) will be implemented January 1, 2011, through the Medicare Physician Fee Schedule Database (MPFSDB) and Integrated Outpatient Code Editor (IOCE).


Other Billing Requirements :

 Remember that G0438 is for the first AWV only. Thus, submission of G0438 for a beneficiary for whom a claim with code G0438 has already been paid will result in a denial of the later G0438 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.).



Remember also that the G0438 or G0439 must not be billed within 12 months of a previous billing of a G0402 (IPPE), G0438, or G0439 for the same beneficiary. Such subsequent claims will be denied with a CARC of 119 (Benefit maximum for this time period or occurrence has been reached) and a RARC of N130 (Consult plan benefitdocuments/guidelines for information about restrictions for this service). If a claim for a G0438 or G0439 is submitted within the first 12 months after the effective date of the beneficiary’s first Medicare Part B coverage, it will also be denied as that beneficiary is eligible for the IPPE or “Welcome to Medicare” physical. Such claims with G0438 or G0439 will be denied with a CARC of 26 (Expenses incurred prior to coverage) and a RARC of N130.


Who Is Covered


All Medicare beneficiaries who are both:

* Not within 12 months after the effective date of their first Medicare Part B coverage period

* Have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months


Frequency

* Once in a lifetime for G0438 (first AWV)

* Annually for G0439 (subsequent AWV) Medicare Beneficiary Pays

* Copayment/coinsurance waived

* Deductible waived


Can other medical services be performed at the same time as an AWV? If so, how are they coded?

Answer:

The HCPCS codes for the first AWV service (HCPCS code G0438) and subsequent AWV services (HCPCS code G0439) do not include other preventive services that are paid separately by Medicare. Such services can be provided on the same day as the AWV, but they should be identified separately using the appropriate HCPCS/CPT codes. When practitioners perform preventive services in addition to an AWV visit, billing and payment edits will continue to apply for the additional services.

If the need arises to perform a significant, separately identifiable, medically necessary evaluation and management (E/M) service in addition to the AWV, CPT codes 99201-99215 may be reported with CPT modifier 25, depending on the clinical appropriateness of the circumstances. Some of the components of a medically necessary E/M service (e.g., a portion of history or physical examination) may have been part of the AWV and should not be included when determining the most appropriate E/M level of service to bill. These services must be medically necessary to treat an illness or injury or to improve the functioning of a malformed body member.

2014 Coding Procedures Update for Medicare Advantage

The following Medicare Advantage plans have updated coding procedures for 2014:
•    AARP® MedicareComplete®
•    UnitedHealthcare® MedicareComplete®
•    UnitedHealthcare® Dual Complete™
•    UnitedHealthcare MedicareDirect™

Medicare Part B covers the following types of wellness exams:

•    Welcome to Medicare Visit (Initial Preventive Physical Exam (IPPE))
•    Annual Wellness Visit (Personalized Prevention Plan Services (PPPS))

Medicare members are entitled to receive a Welcome to Medicare Visit within the first 12 months of Medicare Part B coverage for a $0 copayment. Medicare members are also entitled to receive an Annual Wellness Visit every calendar year thereafter for a $0 copayment for specific services to be provided during each type of visit.

All Medicare Advantage plans insured by UnitedHealthcare (HMO, PPO, POS, PFFS and SNP) also cover the Welcome to Medicare and Annual Wellness Visits for a $0 copayment in-network (or out-ofnetwork for PFFS members).

Wellness Visit Submission Codes

Providers may submit the following code for the one-time Welcome to Medicare Visit:
•    G0402

Providers may submit one of the following codes for the Annual Wellness Visit:
•    G0438 (first visit)
•    G0439 (subsequent visit

In 2014 our plans also cover an Annual Routine Physical Examination performed by the member’s
•    Primary Care Physician (PCP), in addition to the Medicare-covered services billed using the following codes:
•    99385-99387
•     99395-99397

Notes on Annual Routine Physical Examination coverage:

•    If you bill these 99XXX codes, you must provide a head-to-toe exam and cannot bill for a
separate breast and pelvic exam, a Digital Rectal Exam (DRE), or counseling to promote healthy behavior. See the Definitions section for details on the specific components included in the visit. All Medicare Advantage plans insured by United Healthcare offered to individuals cover this benefit in 2014, except H0543-153 AARP Medicare Complete Secure Horizons Plan 3 offered in Los Angeles, Orange, Riverside and San Bernardino counties in California. Coverage on employer group Medicare Advantage plans may vary.

Additionally, all plans offer a Pap/Pelvic Exam (including pelvic exam and the pap collection with coverage periodicity following Medicare guidelines: covered annually for those at high risk and every 2 years for all other women) for a $0 copay. A separate Evaluation and Management (E/M) code may be billed only if a separately identifiable E/M service was provided. The following code is accepted:

•    Exam: G0101
•    When members see an obstetrician or gynecologist who is not their assigned PCP for a routine pap/pelvic
•    exam, only the Medicare-covered annual pap/pelvic service should be performed and billed. Members
•    should be referred to their assigned PCP if a more comprehensive preventive service is warranted.


Billing Requirements

Two new HCPCS codes, G0438 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit, (Short descriptor – Annual wellness first)  and G0439 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit, (Short descriptor – Annual wellness subseq) will be implemented January 1, 2011, through the Medicare Physician Fee Schedule Database (MPFSDB) and Integrated Outpatient Code Editor (IOCE).

Effective for services on or after January 1, 2011, Medicare contractors will pay claims containing these codes provided the requirements for coverage and eligibility are met. Institutional providers need to submit these claims via Types of Bill (TOB) 12X, 13X, 22X, 23X, 71X, 77X, or 85X. Institutional providers will be paid as follows:

 ** For services performed on a 12X TOB and 13X TOB, hospital inpatient Part B and hospital outpatient, payment shall be made based on the MPFS.

 ** For TOBs 22X and 23X, skilled nursing facilities will be paid based on the MPFS.

 ** Rural Health Clinics (TOB 71X) and Federally Qualified Health Centers (TOB 77X) will be paid based on the all-inclusive rate. However, for TOBs 71X and 77X, the AWV does not qualify for separate payment with another encounter.

 ** For services performed on an 85X TOB, Critical Access Hospital (CAH), pay based on reasonable cost.

 ** CAHs claims (submitted on TOB 85X with revenue codes 096X, 097X, and 098X) will be paid based on MPFS.

 ** For inpatient or outpatient services in hospitals in Maryland, make payment according to the Health Services Cost Review Commission.


Other Billing Requirements

Remember that G0438 is for the first AWV only. Thus, submission of G0438 for a beneficiary for whom a claim with code G0438 has already been paid will result in a denial of the later G0438 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.).

Remember also that the G0438 or G0439 must not be billed within 12 months of a previous billing of a G0402 (IPPE), G0438, or G0439 for the same beneficiary. Such subsequent claims will be denied with a CARC of 119 (Benefit maximum for this time period or occurrence has been reached) and a RARC of N130 (Consult plan benefit documents/guidelines for information about restrictions for this service).

If a claim for a G0438 or G0439 is submitted within the first 12 months after the effective date of the beneficiary’s first Medicare Part B coverage, it will also be denied as that beneficiary is eligible for the IPPE or “Welcome to Medicare” physical. Such claims with G0438 or G0439 will be denied with a CARC of 26 (Expenses incurred prior to coverage) and a RARC of N130


FAQs:

Q: Does CIP allow providers to bill wellness exams and physical exam codes in 2013? 

A: CIP allows both a wellness exam (HCPCS G0438, G0439 codes) and physical exam (CPT 99381-99387 and CPT 99391-99397) to be billed annually in 2013 and a ‘Welcome to Medicare’ physical (HCPCS G0402), if applicable.

Q: What are the ‘G codes’ that were created by CMS for wellness visits?

A: The two wellness codes are: G0438 –Annual Wellness Visit (AWV) which includes a personalized prevention plan (PPPS) and G0439 Subsequent Annual Wellness Visit (AWV); which includes a personalized prevention plan (PPPS).

Q: When is it appropriate to bill the subsequent annual wellness visit (AWV) CPT G0439 code?

A: The HCPCS G0439 code is to be used in the years subsequent to the submission of G0438 for the initial annual wellness visit, even if the member changes physicians.



What is the difference between the G codes and CPT comprehensive preventive service codes?

• Requirements for G0438-G0439 differ from 99381- 99397

– AWV does NOT include a complete physical exam

• Annual Wellness Visit focuses on:

– identification of risk factors,

– personalized health advice, and

– referral for

• additional preventive services, and

• lifestyle interventions (may or may not be covered by Medicare)


What ICD-9-CM Diagnosis Code would be appropriate when reporting an AWV Preventive Service Code (i.e., G0438 or G0439)? 

Answer: No specific diagnosis code required, but V70.0 Routine general medical examination at health care facility is reasonable


Wellness Visit Submission Codes

Please submit the following code for the one-time Welcome to Medicare Visit: • G0402

Please submit one of the following codes for the Annual Wellness Visit: • G0438 (first visit) • G0439 (subsequent visit) In 2015, our plans also cover an Annual Routine Physical Examination by the member’s Primary Care Physician (PCP) and can be billed using the following codes:

• 99385-99387 • 99395-99397


Annual Routine Physical Examination coverage:

• If you bill these 99XXX codes, you must provide a head-to-toe exam and cannot bill for a separate breast and pelvic exam, a Digital Rectal Exam (DRE), or counseling to promote healthy behavior. See the Definitions section for details on the specific components included in the visit. All UnitedHealthcare Medicare Advantage plans for individuals include this benefit in 2015. Coverage on employer group Medicare Advantage plans may vary.



G0438  Annual Wellness Visit (AWV); includes a personalized prevention plan (PPPS)  

This code can only be used for a beneficiary who is no longer within the first twelve  months after the effective date of Part B coverage; and if he/she has not already  received either an IPPE or an AWV within the past twelve months.  Medicare pays  for only one Initial Annual Wellness Visit per beneficiary per lifetime; all  subsequent wellness visits must be billed as a Subsequent  annual Wellness Visit  (G0439).

G0439 Subsequent Annual Wellness Visit (AWV); includes a personalized prevention plan  (PPPS)

This code is to be used in the years subsequent to the submission of G0438 for the initial annual wellness visit, even if the patient switches to a new doctor.  (See MLM  Matters number MM7079 for details.)

E&M service during the same encounter as an IPPE or AWV: 

When the physician provides a significant,+separately+identifiable medically necessary E&M  service in addition to the IPPE or AWV, CPT codes 99201>99215 may be reported depending on  the clinical appropriateness of the circumstances.  CPT modifier >25 must be  deppended to the  medically necessary E&M service identifying this service as a significant, separately identifiable  service from the IPPE or AWV code reported (G0402, G0438 or G0439 whichever applies). 


First Annual Wellness Visit (AWV) (G0438) includes a personalized prevention plan service (PPPS). This code can only be used for a beneficiary who is no longer within the first twelve months after the effective date of Medicare Part B coverage; and if he/she has not already received either an IPPE or an AWV within the past twelve months. Medicare pays for only one initial AWV per beneficiary per lifetime.


Subsequent AWV’s (G0439) include a PPPS also. This code is to be used in the years subsequent to the submission of G0438 for the initial AWV, even if the patient switches to a new physician. Medicare pays annually after eleven full months have passed since the last AWV.

Voluntary Advance Care Planning (ACP) means the face-to-face service between a physician (or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms. An advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time. IPPE (G0402) includes:

1. Review of medical and social history

2. Review of potential (risk factors) for depression

3. Review of functional ability and level of safety

4. Measurement of height, weight, body mass index, blood pressure, visual acuity screen, and other factors deemed appropriate

5. Discussion of end-of-life planning, upon agreement of the individual

6. Education, counseling and referrals based on results of review and evaluation services performed during the visit, including a brief written plan such as a checklist, and if appropriate, education, counseling and referral for obtaining an electrocardiogram (EKG, ECG) IPPE-Related Screenings:

* The screening EKG (G0403, G0404, G0405), when done as a referral from an IPPE, is optional and only covered once during a beneficiary’s lifetime.

* G0389 is a one-time only ultrasound screening for an Abdominal Aortic Aneurysm (AAA) and can be done as the result of a referral from an IPPE for Medicare beneficiaries with certain risk factors.FAQs:

Q: Does CIP allow providers to bill wellness exams and physical exam codes in 2013?

A: CIP allows both a wellness exam (HCPCS G0438, G0439 codes) and physical exam (CPT 99381-99387 and CPT 99391-99397) to be billed annually in 2013 and a ‘Welcome to Medicare’ physical (HCPCS G0402), if applicable.

Q: What are the ‘G codes’ that were created by CMS for wellness visits?

A: The two wellness codes are: G0438 –Annual Wellness Visit (AWV) which includes a personalized prevention plan (PPPS) and G0439 Subsequent Annual Wellness Visit (AWV); which includes a personalized prevention plan (PPPS).

Q: When is it appropriate to bill the subsequent annual wellness visit (AWV) CPT G0439 code?

A: The HCPCS G0439 code is to be used in the years subsequent to the submission of G0438 for the initial annual wellness visit, even if the member changes physicians.


SERVICE HCPCS/CPT CODES ICD-9-CM CODES WHO IS COVERED FREQUENCY BENEFICIARY PAYS 

Initial Preventive Physical Examination (IPPE) Also known as the “Welcome to Medicare Preventive Visit” G0402 – IPPE G0403 – EKG for IPPE G0404 – EKG tracing for IPPE G0405 – EKG interpret & report for IPPE No specific diagnosis code Contact the local Medicare Contractor for guidance All Medicare beneficiaries whose first Part B coverage began on or after 01/01/05 Important – The screening EKG is an optional service that may be performed as a result of a referral from an IPPE Once in a lifetime Must furnish no later than 12 months after the effective date of the first Medicare Part B coverage G0402:

• Copayment/coinsurance waived Deductible waived G0403, G0404, and G0405:

•   Copayment/coinsurance applies Deductible applies Annual Wellness Visit (AWV) G0438 – Initial visit G0439 – Subsequent visit No specific diagnosis code Contact the local Medicare Contractor for guidance All Medicare beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period and who have not received an IPPE or AWV within the past 12 months

• • Once in a lifetime for G0438 Annually for G0439

• Copayment/coinsurance waived Deductible waived  Ultrasound

Screening for Abdominal Aortic Aneurysm (AAA) G0389 – Ultrasound exam AAA screening No specific diagnosis code Contact the local Medicare Contractor for guidance Medicare beneficiaries with certain risk factors for AAA Important – Eligible beneficiaries must receive a referral for an ultrasound screening for AAA as a result of an IPPE Once in a lifetime •
• Copayment/coinsurance waived Deductible waived


What is the IPPE ?

• One-time visit, covered within first 12 months of Part B enrollment and includes –
• Review of medical and social history
• Review of potential (risk factors) for depression
• Review of functional ability and level of safety
• Measurement of height, weight, body mass index, blood pressure, visual acuity screen, and other factors deemed appropriate
• Discussion of end-of-life planning, upon agreement of the individual
• Education, counseling and referrals based on results of review and evaluation services performed during the visit, including a brief written plan such as a checklist, and if appropriate, education, counseling and referral for obtaining an electrocardiogram (a/k/a EKG, ECG)

Who Can Provide an IPPE ?

Physician (doctor of medicine or osteopathy)

• Qualified non-physician practitioner:
• Nurse practitioner
• Physician assistant
• Clinical nurse specialist



Who can bill for the IPPE?

These services typically are provided in a physician office. When the services are provided in a facility, the following institutions can bill:
o Hospitals for inpatients (TOB 12X) and outpatients (TOB 13x)
o Skilled Nursing Facilities for inpatients (TOB 22X)
o Rural Health Centers (TOB 71X)
o Federally Qualified Health centers (TOB 77X)
o Critical Access Hospitals (TOB 85X)

Although a diagnosis code must be reported on the claim, there are no specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes that are required for the IPPE; therefore, Medicare providers should chose an appropriate ICD-9-CM diagnosis code.

IPPE-Related Screening for Abdominal Aortic Aneurysm (AAA)

A one-time only ultrasound screening for an Abdominal Aortic Aneurysm (AAA) can be done as the result of a referral from an IPPE for Medicare beneficiaries with certain risk factors. The code for billing the AAA ultrasound screening is below:

G0389 – Ultrasound, B-scan and or real time with image documentation; AAA screening Preparing Patients for the IPPE

Stephanie Frilling

Providers can help Medicare beneficiaries get ready for their IPPE by encouraging them to come prepared with the following information:
• Medical records, including immunization records;
• Family health history, in as much detail as possible; and
• A full list of medications and supplements, including calcium and vitamins – how often and how much of each is taken. Who Can Provide an AWV *
• A “health professional” meaning a:
• Physician
• Physician assistant
• Nurse practitioner
• Clinical nurse specialist
• Medical professional (including a health educator, a registered dietitian, or nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician

The following G-codes identify the AWV for Medicare payment:
• G0438 (Annual wellness visit, including Personalized Prevention Plan Service, first visit), and
• G0439 (Annual wellness visit, including Personalized Prevention Plan Service, subsequent visit). Who can bill for the AWV*

These services typically are provided in a physician office. When the services are provided in
a facility, the following institutions can bill:
o Hospital inpatients (TOB 12X) and outpatients (TOB 13x)
o Skilled Nursing Facilities inpatients (TOB 22X) and outpatients (23X)
o Rural Health Centers (TOB 71X)
o Federally Qualified Health centers (TOB 77X)
o Critical Access Hospitals (TOB 85X)

Note: Medicare makes a single fee schedule payment for a beneficiary’s AWV when provided in a physician office or hospital outpatient department

Diagnosis Coding

• Although a diagnosis code must be reported on the claim, there are no specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes that are required for the AWV; therefore, Medicare providers should chose an appropriate ICD-9-CM diagnosis code or contact the local Medicare contractor for guidance.

Preparing Patients for the AWV Stephanie Frilling

Providers can help Medicare beneficiaries get ready for their AWV by encouraging them to come prepared with the following information:
• Medical records, including immunization records;
• Family health history, in as much detail as possible;
• A full list of medications and supplements, including calcium and vitamins – how often and how much of each is taken; and
• A full list of current providers and suppliers involved in providing care.


1 comment:

  1. Can we allow G0439-25 with CPT 93000 for the Same visit?

    ReplyDelete

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