Wellness visit CPT codes G0402, G0438, G0439 - Medicare welcome - Medical billing cpt modifiers and list of Medicare modifiers. (2022)



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.

Medicare HMO annual visit CPT code G0402, G0438 and G0439 coverage

Medicare Advantage Program Coding for Welcome to Medicare and Annual Wellness Visits

Vital REMINDER: Florida Blue, as a Medicare Advantage arrangement with four contracts with the Centers for Medicare and Medicaid Services (CMS), advises you that Medicare Advantage Members are qualified for one Welcome to Medicare visit and also an Annual Wellness visit. At the point when documenting these Medicare Advantage visit claims, it is essential for you to utilize the right system codes r to keep away from case dissents.

• Cpt Code G0402 – Initial Preventive Physical Examination (IPPE) or Welcome to Medicare Visit

• Cpt Code G0438 – Annual Wellness Visit (AWV); incorporates a customized avoidance arrangement (PPPS)

(Video) Annual Wellness Visits (AWV): CPT Codes, Billing and Reimbursements

• Cpt Code G0439 – Subsequent Annual Wellness Visit (AWV); incorporates a customized avoidance arrangement (PPPS)

Additionally, please allude to the notice of February 2015, Update: Medicare Advantage Program Coding for Annual Wellness Visits .

NOTE: Our arrangements don’t cover routine physical examinations normally charged utilizing the Preventive Medicine Services system codes 99381 – 99397. Powerful for administrations performed on and after January 1, 2016, all visits charged with these method codes for Medicare Advantage individuals will be denied.

Keep in mind to check part qualification and advantages electronically through Availity

Stay avant-garde with the most recent Medicare preventive administrations news for Medicare recipients by signing into the CMS site at http://www.cms.gov/and selecting the Outreach and Education

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.

(Video) Wellness versus Physical for the Medicare Patient

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

(Video) Medicare Annual Wellness or Preventive Care Codes - Chapter 23

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.

Medicare complete Guide for Annual visit

Medicare covers an Annual Wellness Visit (AWV) providing Personalized Prevention Plan Services (PPPS) for beneficiaries who:

* Are no longer 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

This publication is divided into two sections: the first explains the elements of a beneficiary’s initial AWV; the second explains the elements of all subsequent AWVs. You must provide all elements of the AWV prior to submitting a claim for the AWV.

Acquire Beneficiary Information

Action Elements

Administer HRA * Collect self-reported information from the beneficiary You or the beneficiary can complete the HRA before or during the AWV encounter; it should take no more than 20 minutes

* Account for and tailor to the communication needs of underserved populations, persons with limited English proficiency, and persons with health literacy needs

* At a minimum, address the following topics:

Demographic data Self-assessment of health status
Psychosocial risks
Behavioral risks

Activities of Daily Living (ADLs), including but not limited to: dressing, bathing, and walking

Instrumental ADLs, including but not limited to: shopping, housekeeping, managing own medications, and handling finances Establish a list of current providers and suppliers

Include current providers and suppliers that regularly provide medical care to the beneficiary Establish the beneficiary’s medical/family history

At a minimum, collect and document the following:

* Medical events of the beneficiary’s parents, siblings, and children, including diseases that may be hereditary or place the beneficiary at increased risk

* Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments

* Use of, or exposure to, medications and supplements, including calcium and vitamins

Review the beneficiary’s potential risk factors for depression, including current or past experiences with depression or other mood disorders

Use any appropriate screening instrument for beneficiaries without a current diagnosis of depression, which you may select from various available standardized screening tests designed for this purpose and recognized by national professional medical organizations Review the beneficiary’s functional ability and level of safety

Use direct observation of the beneficiary, or select appropriate screening questions or a screening questionnaire from various available screening questions or standardized questionnaires recognized by national professional medical organizations to assess, at a minimum, the following topics:

* Ability to successfully perform ADLs
* Fall risk
* Hearing impairment
* Home safety Counsel Beneficiary Action Elements

Establish a written screening schedule for the beneficiary, such as a checklist for the next 5 to 10 years, as appropriate

Base written screening schedule on:
* Age-appropriate preventive services Medicare covers
* Recommendations from the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP)
* The beneficiary’s HRA, health status and screening history, and age-appropriate preventive services covered by Medicare Establish a list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended or underway for the beneficiary

Include the following:
* Mental health conditions
* Risk factors or conditions identified through an IPPE
* Treatment options and their associated risks and benefits

Furnish personalized health advice to the beneficiary and appropriate referrals to health education or preventive counseling services or programs
Include referrals to educational and counseling services or programs aimed at:
* Community-based lifestyle interventions to reduce health risks and promote selfmanagement and wellness, including:

Fall prevention Nutrition Physical activity Tobacco-use cessation Weight loss Furnish, at the discretion of the beneficiary, advance care planning services

Include discussion about:

* Future care decisions that may need to be made
* How the beneficiary can let others know about care preferences
* Explanation of advance directives, which may involve the completion of standard forms Acquire Updated Beneficiary Information

Action Elements

Update HRA * Collect self-reported information from the beneficiary You or the beneficiary can update the HRA before or during the AWV encounter; it should take no more than 20 minutes

* At a minimum, address the following topics:

Demographic data

Self-assessment of health status

(Video) Annual Wellness Visit - Live Webinar Demonstration Series Part 2: AWV Components and Billing

Psychosocial risks Behavioral risks

ADLs, including but not limited to: dressing, bathing, and walking

Instrumental ADLs, including but not limited to: shopping, housekeeping, managing own medications, and handling finances Update the list of current providers and suppliers

Include current providers and suppliers regularly involved in providing medical care to the beneficiary Update the beneficiary’s medical/family history

At a minimum, update and document the following:

* Medical events of the beneficiary’s parents, siblings, and children, including diseases that may be hereditary or place the beneficiary at increased risk
* Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments
* Use of, or exposure to, medications and supplements, including calcium and vitamins Assess Obtain the following measurements:
* Weight (or waist circumference, if appropriate) and blood pressure
* Other routine measurements as deemed appropriate based on medical and family history Detect any cognitive impairment the beneficiary may have

Assess the beneficiary’s cognitive function by direct observation, with due consideration of information obtained via beneficiary reports and concerns raised by family members, friends, caretakers, or othersCounsel Beneficiary Action Elements Update the written screening schedule for the beneficiary

Base written screening schedule on:
* Age-appropriate preventive services Medicare covers
* Recommendations from the USPSTF and the ACIP
* The beneficiary’s HRA, health status and screening history, and age-appropriate

preventive services covered by Medicare Update the list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or underway for the beneficiary

Include the following:
* Mental health conditions
* Risk factors or conditions identified
* Treatment options and their associated risks and benefits

Action Elements Furnish personalized health advice to the beneficiary and a referral, as appropriate, to health education or preventive counseling services or programs

Include referrals to educational and counseling services or programs aimed at:
* Community-based lifestyle interventions to reduce health risks and promote selfmanagement and wellness, including:

Fall prevention Nutrition Physical activity Tobacco-use cessation Weight loss Furnish, at the discretion of the beneficiary, advance care planning services

Include discussion about:

* Future care decisions that may need to be made
* How the beneficiary can let others know about care preferences
* Explanation of advance directives, which may involve the completion of standard forms Use the following HCPCS codes to file claims for AWVs.

AWV HCPCS Codes and Descriptors
AWV HCPCS Codes Billing Code Descriptors
G0438 Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit
G0439 Annual wellness visit, includes a personalized prevention plan of service (PPS),

subsequent visit Diagnosis

You must report a diagnosis code when submitting a claim for the AWV. Since you are not required to document a specific diagnosis code for the AWV, you may choose any diagnosis code consistent with the beneficiary’s exam.

Billing Medicare Part B covers an AWV if performed by a:

* Physician (a doctor of medicine or osteopathy)

* Qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist)

* Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of medical professionals who are directly supervised by a physician (doctor of medicine or osteopathy) When you furnish a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service along with the AWV, Medicare may pay for the additional service. Report the additional Current Procedural Terminology (CPT) code with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member. ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a beneficiary to discuss the beneficiary’s wishes and preferences for medical treatment if he or she were unable to speak or make decisions in the future. You can provide the ACP at the time of the AWV, at the beneficiary’s discretion.

Coding Use the following CPT codes to file claims for ACP as an optional element of an AWV.

ACP CPT Codes and Descriptors
ACP CPT Codes Billing Code Descriptors

99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

99498 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Diagnosis

You must report a diagnosis code when submitting a claim for ACP as an optional element of an AWV. Since you are not required to document a specific diagnosis code for ACP as an optional element of an AWV, you may choose any diagnosis code consistent with a beneficiary’s exam.

What are the other Medicare Part B preventive services*

* Alcohol Misuse Screening and Counseling
* Bone Mass Measurements
* Cardiovascular Disease Screening Test
* Colorectal Cancer Screening
* Counseling to Prevent Tobacco Use
* Depression Screening
* Diabetes Screening
* Diabetes Self-Management Training (DSMT)
* Glaucoma Screening
* Hepatitis C Virus (HCV) Screening
* Human Immunodeficiency Virus (HIV) Screening
* Influenza, Pneumococcal, and Hepatitis B Vaccinations and their Administration
* Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD), also known as a CVD risk reduction visit
* IBT for Obesity
* IPPE (also called the “Welcome to Medicare Preventive Visit”)
* Medical Nutrition Therapy (MNT)
* Prostate Cancer Screening
* Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests
* Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
* Screening for Hepatitis B Virus (HBV) Infection
* Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs
* Screening Mammography
* Screening Pap Tests
* Screening Pelvic Examination (includes a clinical breast examination)
* Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) Visit the MLN’s Preventive Services Educational Tool for additional resources on Medicare preventive services.

Who is eligible for the AWV?

Medicare covers an AWV for all beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period, and who have not had either an IPPE or an AWV within the past 12 months. Medicare pays for only one first AWV per beneficiary per lifetime and one subsequent AWV per year thereafter.

Is the AWV the same as a beneficiary’s yearly physical?

No. The AWV is not a routine physical checkup that some seniors may get periodically from their physician or other qualified non-physician practitioner. Medicare does not cover routine physical examinations.

Are clinical laboratory tests part of the AWV?

No. The AWV does not include any clinical laboratory tests, but you may make referrals for such tests as part of the AWV, if appropriate.

Do deductible or coinsurance/copayment apply for the AWV?

No. Medicare waives both the coinsurance or copayment and the Medicare Part B deductible for the AWV.

Can I bill an electrocardiogram (EKG) and the AWV on the same date of service?

Generally, you may provide other medically necessary services on the same date of service as an AWV. The deductible and coinsurance/copayment apply for these other medically necessary services.

How do I know if a beneficiary already got his/her first AWV from another provider and know whether to bill for a subsequent AWV even though this is the first AWV I provided to this beneficiary*

You have different options for accessing AWV eligibility information depending on where you practice. You may access the information through the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS) or through the provider call center Interactive Voice Responses (IVRs). CMS suggests providers check with their Medicare Administrative Contractor (MAC) to see what options are available to verify beneficiary eligibility. Contact your MAC for more information.

(Video) BILLING TIPS ON WELCOME TO MEDICARE VISIT AND ANNUAL WELLNESS VISIT

PREPARING ELIGIBLE MEDICARE

BENEFICIARIES FOR THE AWV Providers can help eligible 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
* A full list of current providers and suppliers involved in Page 14 of 17 providing care

FAQs

What is the modifier with G0438? ›

Along with code G0438 or 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."

What can be billed with G0439? ›

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.

Can G0438 and G0402 be billed together? ›

Remember, you must not bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient.

What is the difference between G0438 and G0439? ›

As a reminder, there are two codes related to the AWV: G0438 (includes a personalized prevention plan of service, initial visit) and G0439 ( includes a personalized prevention plan of service, subsequent visit).

What codes can be billed with G0402? ›

Coding procedure code G0402: Initial Preventive Physical Examination; face-to-face visit, services limited to a new patient during the first 12 months of Medicare enrollment. The screening EKG/ ECG is billable with HCPCS code(s) G0403,G0404, or G0405, when it is a result of a referral from an IPPE.

What is CPT code G0402? ›

HCPCS code G0402 for Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment as maintained by CMS falls under Initial Services for Medicare Enrollment .

How often can CPT code G0439 be billed? ›

Claims for HCPCS code G0439- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); subsequent, billed more than once within 12 months of G0438 or G0439 will be denied.

What is CPT code G0439? ›

Basics of HCPCS code G0402, G0438 & G0439. The Annual Wellness Visit (AWV) is a free annual preventive visit which focuses on providing a personalized prevention plan of services for Medicare Advantage members. The AWV is not a routine physical exam.

Is CPT G0402 covered by Medicare? ›

A - Medicare AWVs consist of three specific visit types statutorily covered by Medicare with no co-pay or deductible. They are the IPPE (the “Welcome to Medicare” visit, G0402), the initial AWV (G0438), and the subsequent AWV (G0439). These visits do not require a comprehensive physical exam.

Does G0444 need a modifier when billed with G0439? ›

G0444 may not be billed with G0402 (IPPE) and G0438 (Initial AWV). However, if furnished and properly documented you CAN bill G0444 with G0439 (subsequent AWV). I would not use Modifier 25 on AWV/IPPE due to the nature of the non-E/M visit, however Modifier 59 and XU might be appropriate.

Does G0439 include ECG? ›

And there is no screening EKG for the G0438 and G0439. The 'free' EKG is only with the IPPE (G0402).

What does G0402 include? ›

The four HCPCS codes used to report IPPE services and ECG screenings are: G0402 – IPPE is a face to face visit. Service is limited to a new beneficiary during the first 12 months of Medicare enrollment.

What does Medicare reimburse G0438? ›

INITIAL ANNUAL WELLNESS VISIT (G0438)

This visit is offered to patients only once in their lifetime. They are eligible within 11 calendar months after their IPPE. The reimbursement is around $173.

What is the difference between a Medicare wellness exam and a physical? ›

A physical exam helps your doctor figure out what the problem is and what needs to be done. When you're healthy and feeling good, you want to stay that way. A wellness exam helps your doctor understand what's working for you and how to best support your continued health and well-being.

What is the CPT code for wellness visit? ›

Coding and Billing a Medicare AWV

Medicare will pay a physician for an AWV service and a medically necessary service, e.g. a mid-level established office visit, Current Procedural Terminology (CPT) code 99213, furnished during a single beneficiary encounter.

Are G codes accepted by Medicare? ›

Check Out 2021 HCPCS Level II

1, Medicare recognizes 1,278 HCPCS Level II G codes, explains Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

What is HCPCS code G0438? ›

G0438 is a valid 2022 HCPCS code for Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit or just “Ppps, initial visit” for short, used in Medical care.

How often does Medicare pay for G0439? ›

A: Once in a lifetime for G0438 (i.e., the first AWV) and annually for G0439 (i.e., subsequent AWVs). Q: How much do patients pay for services covered by G0438 and G0439? A: $0. The copayment/coinsurance is waived, as is the deductible.

Can G0439 be billed as telehealth? ›

The Medicare AWV codes (HCPCS codes G0438 and G0439) are on the list of approved Medicare telemedicine services. CMS states that self-reported vitals may be used when a beneficiary is at home and has access to the types of equipment they would need to self-report vitals. The visit must also meet all other requirements.

Can 99397 and G0439 be billed together? ›

Correct you can only bill one or the other (medicare annual wellness or a preventative examination).

What is the 82 modifier used for? ›

CPT Modifier 82 represents assistant at surgery by another physician when a qualified resident surgeon is not available to assist the primary surgeon. This modifier is not intended for use by non-physicians assisting at surgery (e.g., Nurse Practitioners or Physician Assistants).

What is the SG modifier for? ›

Ambulatory surgical center (ASC) facility service.

What is the QJ modifier used for? ›

Submit this modifier with services that are rendered to a prisoner or a patient in a jurisdiction that meets the conditions of 42 CFR 411.4(b).

Can 99397 and G0438 be billed together? ›

Medicare does discourage this and says there is too much 'crossover' between these two preventive services. We usually see a 99213 or 99214 with a G0438 or G0439 to represent the problem management outside the AWV. If you bill G0438/G0439 and a 99397, recognize that Medicare does not cover the 99397.

What is the modifier 59 used for? ›

Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

What is a 27 modifier used for? ›

The CPT defines modifier –27 as “multiple outpatient hospital evaluation and management encounters on the same date.” HCFA will recognize and accept the use of modifier –27 on hospital OPPS claims effective for services on or after October 1, 2001.

What is the 59 modifier for CPT codes? ›

Modifier 59 Distinct Procedural Service indicates that a procedure is separate and distinct from another procedure on the same date of service. Typically, this modifier is applied to a procedure code that is not ordinarily paid separately from the first procedure but should be paid per the specifics of the situation.

What modifiers are not accepted by Medicare? ›

Medicare will automatically reject claims that have the –GX modifier applied to any covered charges. Modifier –GX can be combined with modifiers –GY and –TS (follow up service) but will be rejected if submitted with the following modifiers: EY, GA, GL, GZ, KB, QL, TQ.

What is the Q7 modifier? ›

HCPCS Modifier Q7 is used to report one class A finding as it pertains to routine foot care. Guidelines and Instructions. Routine foot care is not a covered Medicare benefit. Medicare assumes that the beneficiary or caregiver will perform these services by themselves and they are therefore excluded from coverage.

What is the ZZ modifier? ›

Modifiers in the WA through ZZ range, with the exception of YY (second opinion) and ZZ (third opinion), are reserved for local assignment. Modifiers Q, K, and G modifiers are reserved for CMS. The remainder of the alpha-numeric and numeric series is reserved for national modifiers and AMA modifiers, respectively.

Which modifier goes first TC or 59? ›

If you code two pricing modifiers that include either a professional or technical component (26 or TC), always use the 26 or TC first, followed by the second pricing modifier. If you have two payment modifiers, for example 51 and 59, enter 59 first and 51 second.

What does GG modifier stand for? ›

HCPCS modifier GG is used to report performance and payment of a screening mammography and diagnostic mammography on the same patient on the same day. Guidelines and Instructions. Medicare allows additional mammogram films to be performed without an additional order from the treating physician.

What is the Q1 modifier used for? ›

Modifier Q1 is used for services defined as a routine clinical service provided in a clinical research study that is in an approved clinical research study. This modifier must be billed in conjunction with diagnosis code V70. 7 (examination of participant in clinical trial) or diagnosis code Z00.

What is included in CPT G0402? ›

Coding procedure code G0402: Initial Preventive Physical Examination; face-to-face visit, services limited to a new patient during the first 12 months of Medicare enrollment. The screening EKG/ ECG is billable with HCPCS code(s) G0403,G0404, or G0405, when it is a result of a referral from an IPPE.

Is CPT G0402 covered by Medicare? ›

A - Medicare AWVs consist of three specific visit types statutorily covered by Medicare with no co-pay or deductible. They are the IPPE (the “Welcome to Medicare” visit, G0402), the initial AWV (G0438), and the subsequent AWV (G0439). These visits do not require a comprehensive physical exam.

How often can CPT code G0439 be billed? ›

Claims for HCPCS code G0439- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); subsequent, billed more than once within 12 months of G0438 or G0439 will be denied.

Videos

1. Coding Medicare Annual vs. Regular Physicals (Part 1)
(MedicalCodingCert)
2. HCGTV: Webinar - Billing for Preventive Visit and a Sick Visit
(HCGTV: Haugen Consulting Group)
3. Welcome to Medicare and Annual Wellness Exams | CCO Club Q&A Webinar #049
(MedicalCodingCert)
4. Using Medicare Wellness Visits to Promote Good Health
(CGS Medicare)
5. Coding Medicare Annual vs. Regular Physicals (Part 2)
(MedicalCodingCert)
6. ABC's of The Annual Wellness Visit
(HealthVisions Delmarva PTN)

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