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    Annual wellness visit clarified by CMS; Codes G0438 and G0439; Annual wellness visit versus routine physical


    Renee Stantz
    My January 10 column about the Centers for Medicare and Medicaid Services (CMS) annual wellness visit (AWV) ( http://MedicalEconomics.com/annual) elicited several questions, addressed here.

    Q: In your column about the Medicare AWV, you listed six elements that may be included in the visits. I read that either verbal or written information about voluntary advance care planning must be provided. Is advance care planning also one of the required elements?

    A: Since issuing a press release about this topic in November, CMS included the element of advance care planning and then removed it, clarifying in Transmittal 138, issued February 15, that "the addition and definition of 'voluntary advance care planning' as a specified element of the AWV has been removed."

    Note that this removal does not prevent you from discussing advance care planning with a patient; it only deletes it as a requirement for the AWV.

    G0438 AND G0439 WITH V70.0

    Q: We have been billing codes G0438 and G0439 with ICD-9 code V70.0, and the claims are being rejected. Which ICD-9 code works with these two CPT codes?

    A: CMS has not issued specific diagnosis codes to support codes G0438 and G0439. Some offices across the country have reported that their carriers have, in error, denied these codes when V70.0 is used.

    Resubmit these claims, but answer a few questions beforehand:

    1. Has the patient become eligible for Medicare within the past 12 months? If a patient is within the first 12 months of his or her Medicare Part B effective date, an initial preventive physical examination (IPPE) should be billed instead of an AWV. These types of claims could receive the following denial code:

    • "This service was denied. Medicare doesn't cover an [AWV] within the first 12 months of your Medicare Part B coverage. Medicare does cover a one-time [IPPE] ("Welcome to Medicare" physical exam) within the first 12 months of your Medicare Part B coverage."

    If an IPPE was performed after January 1, 2011, coinsurance and Part B deductibles are waived for this service. When an electrocardiogram (ECG) is furnished with the IPPE, the deductible and coinsurance will continue to apply for ECG services only.

    If a patient is outside the initial 12-month period, then bill for an AWV.

    2. Has the patient received the initial AWV (code G0438) from another provider? G0438 signifies a once-in-a-lifetime benefit for each patient, and CMS will deny your claim if the agency previously paid for this service for a patient. Denial codes:

    • "This service is paid only once in a patient's lifetime."
    • "Lifetime benefit maximum has been reached for this service/benefit category."
    • Group code "PR" (patient responsibility).

    When billing code G0438, obtain an advanced beneficiary notice (ABN) of noncoverage before rendering the service.

    3. Has the patient received an IPPE or AWV within the past 12 months? It will become increasingly difficult to historically track a patient's care. Therefore, obtain an ABN before performing an AWV. If a patient has received an IPPE or AWV within the past 12 months, the denial codes that you could receive are:

    • "This service was denied because it occurred too soon after your last covered [AWV]. Medicare only covers one [AWV] within a 12-month period."
    • "This service was denied because it occurred too soon after your [IPPE]."

    AWV VERSUS ROUTINE PHYSICAL

    Q: How does the CPT code for the new AWV differ from the 99397 code for a routine physical?

    A: Codes 99381 to 99397 include counseling/anticipatory guidance/risk-factor reduction interventions that are provided at the time of the initial or periodic comprehensive preventive medicine examination. As with the IPPE, however, CMS has delineated clear requirements for codes G0438 and G0439.

    For a full listing of the requirements, see Medicare's Claims Processing Manual, Chapter 18, Section 140.








    The author is a medical consultant based in Indianapolis, Indiana. Do you have a primary care-related coding question you would like to have our experts answer in this column? Send it to
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