Since January 1, 2011, Medicare has extended its coverage to include Annual Wellness Visits. This welcome development was made possible by the Affordable Care Act of 2010, which integrated provisions for this service. In order to bill correctly for these visits, Medicare has assigned two HCPCS codes, specifically G0438 and G0439. Familiarizing oneself with these billing codes can facilitate a better understanding of the expectations that both patients and payers have. This knowledge can also assist in accurately projecting revenues and optimizing staff capacity, thereby promoting efficient and effective care.
Healthcare providers can receive reimbursement for a patient’s first Annual Wellness Visit (AWV) by utilizing the HCPCS code G0438. However, it is important to note that Medicare requires patients to have been enrolled in Medicare Part B for over a year and not undergone an AWV or an Initial Preventive Physical Exam (IPPE) in the past 12 months. G0438 can only be used once per patient. Ensuring compliance with these guidelines is essential for proper billing and efficient care delivery. To ensure the best care for patients and efficient billing practices, healthcare providers must keep themselves updated with the HCPCS code G0438’s guidelines for the first annual wellness visit.
After a patient’s initial Annual Wellness Visit (AWV) covered by HCPCS code G0438, subsequent AWVs can be billed using HCPCS code G0439. However, G0439 can only be used once every 12 months, meaning patients are eligible for it on the first day of the same month the following year. For example, if a patient’s first AWV was billed using G0438 on June 15, 2022, they would be eligible for G0439 on June 1, 2023.
Now, you might be wondering what services are included in these subsequent annual wellness visits. Well, most of them are the same as those covered under G0438, including a review of the patient’s medical history and family history, measurement of vital signs, and screening for cognitive impairment and substance use disorders. The only difference is that G0439 also allows for updates to be made to the patient’s medical history and risk factors, rather than just establishing them.
It’s also important to note that for patients who have been Medicare beneficiaries for less than 12 months, providers should use HCPCS code G0402 for their Welcome to Medicare visit or Initial Preventative Physical Exam (IPPE). And if the annual wellness visit is being conducted at a federally qualified health clinic, they must use HCPCS code G0468 instead of G0438 or G0439. With all these different codes, it’s no wonder healthcare providers need to stay informed and up-to-date to ensure proper billing practices.
Not to mention that both of these codes can also be used to bill against the Remote Patient Monitoring Services. The Centers for Medicare & Medicaid Services (CMS) has recognized the benefits of RPM Services and allowed the care providers to use these codes against their remote services as well.
However, while billing against these codes of RPM Services, your care providers must adhere to all the requirements for these codes. It includes assessing the patient’s health comprehensively, creating a customized prevention plan, and documenting the patient’s health record while using Remote Patient Monitoring Services.
The jumbled up mess between HCPCS code G0438 and G0439 is enough to make anyone’s head spin. But the reason why there are two separate codes is actually quite straightforward. It all boils down to the assumption that the different types of visits take varying amounts of resources, which then get reimbursed at different rates.
For instance, the initial annual wellness visit is like collecting a whole library of information that will be continually updated with each subsequent AWV. This means that HCPCS code G0438 gets reimbursed at a rate that is nearly 50% higher than HCPCS code G0439. So if an organization continually misses using the G0438 code for an initial Medicare AWV and instead uses G0439, it could lead to a veritable smorgasbord of denials and result in a significant loss of revenue.
In the midst of the primary annual wellness visit codes G0438 and G0439, there lies a select group of other codes that may be billed for services rendered during an AWV. However, it is vital to note that a separate note is required to support each service performed with any of these codes.
One of these codes is G0468, which stands for Federally Qualified Health Center (FQHC) visit, IPPE, or AWV. This code covers a FQHC visit that includes an Initial Preventive Physical Examination (IPPE) or Annual Wellness Visit (AWV) and comprises a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving IPPE or AWV.
When billing for AWV services, there are several diagnosis codes to keep in mind, including V70.0 for Initial Annual Wellness Visit and G0439 for Subsequent Annual Wellness Visit. Medicare will pay a physician for both an AWV service and a medically necessary service, such as a mid-level established office visit. However, it is crucial to ensure that the elements of the AWV are not duplicated in the medically necessary service. Physicians must append modifier -25 (significant, separately identifiable service) to the medically necessary E/M service to be paid for both services.
To illustrate, suppose a patient comes in for their Annual Wellness Visit and reports tendonitis. In that case, the billing would appear as follows: CPT ICD9, G0438 V70.0, 99212-25 726.90 (tendonitis).
In order to steer clear of an audit, it is highly crucial to stay informed about the evolving coding requirements related to Medicare annual wellness visits. These requirements are not static, as demonstrated by the 2023 Physician Fee Schedule (PFS) final rule, which modified the HCPCS code descriptors for two preventive services. Specifically, HCPCS G0442 now reads as “Annual alcohol misuse screening, 5 to 15 minutes,” while HCPCS G0444 has been altered to “Annual depression screening, 5 to 15 minutes.” It is important to note that these codes now necessitate a minimum of 15 minutes of services. With updates like these happening fairly frequently, utilizing incorrect codes could result in claims being denied.
As regulations and eligibility criteria change, accurately coding preventive health visits to maximize proper reimbursement can be challenging for business office staff. But, If healthcare organizations don’t have enough revenue, they may not be able to provide good preventive health services, which can hurt patients’ health and well-being in the end.
It’s quite valuable to comprehend the CPT codes for Annual Wellness Visits as it can elevate the financial performance of your healthcare organization and streamline the workflow of your care team. Nonetheless, providing and documenting wellness visits in accordance with evidence-based protocols require a reliable system to manage the entire process.
This is where care coordination software can be your ally as it can safeguard critical information from being forgotten or disregarded. The utilization of such software not only helps your staff perform their duties with more efficiency but also enables patients to achieve better health outcomes.
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