Oops! MAC Denies Annual Wellness Visit Claims

At least one Medicare administrative contractor (MAC) has reportedly denied annual wellness visit (AWV) claims in error. The Patient Protection and Affordable Care Act of 2010 (PPACA) provides for the implementation of Medicare AWVs. Full Medicare Part B coverage and payment of the AWV went into effect Jan. 1.

The Centers for Medicare & Medicaid Services (CMS) instructs providers to report the initial AWV with HCPCS Level II code G0438 Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit and all subsequent AWVs with G0439 Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit.

Medicare providers also must report a diagnostic code on the claim. Although there are no specific ICD-9-CM diagnosis codes required for the AWV, there are certain diagnosis codes providers shouldn’t report—as some providers discovered the hard way.

Cahaba GBA erroneously denied claims for G0438/G0439 when billed with a routine service diagnosis code due to an auto-deny edit. Medicare does not typically pay for routine services. The Part B MAC for jurisdiction 10 (Alabama, Georgia, and Tennessee) says mass adjustments were initiated Jan. 31; no provider action is required. Providers should contact their local contractors for proper coding guidance.

Cahaba GBA also reported, Jan. 14, that the deductible for certain HCPCS Level II preventive/screening codes were applied in error. Certain preventive/screening services are no longer subject to a deductible, effective Jan. 1, implemented by CMS in accordance to the PPACA. Cahaba GBA is correcting their internal files and automatically adjusting claims.

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8 Responses to “Oops! MAC Denies Annual Wellness Visit Claims”

  1. adriana ucros says:

    I would like to know what will be the icd-9 code to bill the annual wellness visit i had been reading a lot and no answer to find please let me know

  2. Katharine Mikula says:

    Adriana: I’ve been paid !!!!!, using V700 as primary dx code. Miracles still ‘do’ happen……
    This article ‘seems’ to explain that G0438 replaces G0402? And do Medicare patient’s get the G0439 every 12 months?

  3. Angela Varnum says:

    G0402 is the IPPE exam for a new Medicare patient within the first 12 months. G0438 is the AWV for the second twelve months and G0439 is foe every AWV thereafter. Good to know you got paid on V70.0

  4. Virginia Grove says:

    Katherine: This new Wellness preventative exam G0438 does NOT replace the Welcome to medicare physicals G0402….It is in addition too….The New Medicare Patient still has 12 months from them becoming eligible to get their Welcome to Medicare Physicals. Then they must wait 12 months before they can be eligible to get their first preventative exam payable under medicare. If you go to your local MAC web site….there should be a link to the preventative services covered by Medicare effective Jan 1 2011 and how they need to be applied.

  5. amal n tosson says:

    if the patient came for preventive evaluation, and providere found patient has a disease for first time.Medicare pays only for 1 visit.which prefered to bill with preventive visit,or establish
    although the provider will prefer to bill preventive to avoid deductible

  6. Vickie Quackenbos says:

    Will all current Mcare pt’s getting a AWV’s done after 1/1/11 be initial G0438? and then after 12 months in 2012 the next one done for that pt be G0439, subsequent.
    This is unless the first well exam for 2011 happens to be their Welcome to Mcare IPPE-G0402, then in 12 months in 2012 they would get G0438 and in 2013 after 12 months they would get G0439.

  7. margi pfaff says:

    I was told that Medicare was not able to accept the G0438 until sometime after April 1st? Are others electronically sending these claims already?

  8. Connie Jo says:

    We have several that Cahaba denied for Non covered services/routine using the V70.0 for the AWV and we also billed the Pap and Mammo. I see there was an issue and these are all from prior to March. Safe to try and resubmit since it appears they are not doing a mass adjustment in Iowa? Thanks.

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