Part B Insider (Multispecialty) Coding Alert

Published on Fri Feb 22, 2013 PDF

When both the facility and the doctor bill for the same service, Medicare ends up double-paying.

You may have been overpaid for annual wellness visits without even knowing it, but your MAC could come calling for a refund soon, if a recent CMS Transmittal is any indication.

When CMS established the annual wellness visit (AWV) codes G0438 and G0439, the agency noted that it would accept claims from facilities furnishing the service, or from physicians performing it. Unfortunately, however, that information was misinterpreted by some providers, so when AWVs were performed by physicians in the facility setting, both the facility and the doctor submitted Medicare claims for the AWV, and both got paid.

In many cases, the physician may not have even known that the facility also submitted a duplicate claim, but whether or not your practice is aware of a double-billing, CMS knows about it, and will be recouping the overpayments going forward, the agency states in Transmittal 1190, issued on Feb. 15.

Beginning on April 1, CMS will have an edit in place that only pays either the professional or institutional claim for the AWV. But that still leaves claims submitted between April 4, 2011 and March 31, 2013 that may include double billings, for which CMS instructs MACs to collect refunds. Although the transmittal doesn’t indicate which party will face the refund requests, Medicare will typically pay the first party who bills, and the provider that bills subsequently will be subject to a refund request.

Caveat: If 11 months passed between the first AWV bill’s date of service and the second AWV date, then the MAC will pay both claims. However, for duplicate claims involving dates of service closer together than that, you could face refund requests.

Because G0438 pays about $170 and G0439 reimburses around $112, you could face significant paybacks, depending on how many AWVs that you and your facility have both billed. Going forward, be sure to coordinate your billing with the facility where your physician performs the AWV so that only one claim goes to the payer.

Resource: To read the CMS transmittal in its entirety, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1190OTN.pdf.