Part B Insider (Multispecialty) Coding Alert

Published on Fri Mar 30, 2012 PDF

The agency provides answers some of your most pressing AWV questions.

Whether you consider yourself a Medicare preventive service expert or you're just ramping up on your Welcome to Medicare and Annual Wellness Visit (AWV) coding, you can benefit from a bit of CMS direction on how to report these services.

Check out the following answers to your most frequently-asked Medicare preventive visit questions, which were answered during CMS's "Medicare Preventive Services National Provider Call" on March 28.

Avoid Incident-to for WTM, AWV Patients

Question 1: Can the "Welcome to Medicare" (WTM) exam or the annual wellness visit (AWV) be reported based on "incident-to" guidelines?

Answer: No. The WTM exam, also referred to as the Initial Preventive Physical Examination (IPPE), "is not subject to incident-to billing," said Stephanie Frilling, health insurance specialist with CMS, during the call. "The payment policy for furnishing services incident-to a physician do not apply to the IPPE, as this service has its own benefit category," she said.

"Likewise, the AWV is not subject to incident to rules," Frilling said. If a non-physician provider such as a nurse practitioner performs either of these services, he must bill under his own NPI, the CMS reps added.

Question 2: Which diagnosis code should be reported with the WTM exam and the AWV?

Answer: CMS does not dictate which ICD-9 code should be linked to the WTM exam code (G0402, Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment). Instead, you should select the most applicable diagnosis code from your physician's documentation.

"An example of diagnosis codes that could be included on the WTM claim are V70.0 (Routine general medical examination at a health care facility), V70.3 (Other general medical examination for administrative purposes), or V70.9 (Unspecified general medical examination)," said CMS's Kathleen Kersell during the call. "These all could be considered acceptable diagnosis codes, as well as any other valid, appropriate diagnosis codes," she said.

As for the AWV, "There are no specific ICD-9 diagnosis codes that are required for the annual wellness visit," said CMS's Thomas Dorsey. He noted that V70.0, V70.3, and V70.9 are being accepted by MACs for the AWV visits as well.

Question 3: If we find a problem during the WTM exam, can we report a separate E/M code for that?

Answer: Yes, "Medicare allows for payment of medically necessary evaluation and management services that are furnished" during the same visit as the IPPE or WTM, Frilling said.

When those E/M services are clinically appropriate, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service code (99201-99215), she said.

A caller asked whether a problem-focused E/M code would be separately payable if the patient is discussing a chronic condition (such as uncontrolled diabetes or hypertension) during the AWV and the physician finds that the chronic condition needs to be addressed on a deeper level, (for instance, if a change in medication is necessary). "Yes they can," CMS reps replied. "If it is medically necessary, you would bill the additional E/M service, and append modifier 25 to that claim line for payment," she added.

Don't Report G0439 for 'Results' Visit

Question 4: Is G0439 (Annual wellness visit, includes a personalized prevention plan of service, subsequent visit) meant to be used for a follow-up visits to discuss the results of the initial visit, or is it for visits in subsequent years?

Answer: "You can only use G0438 (Annual wellness visit; includes a personalized prevention plan of service, initial visit) one time, so the next year you'll use the G0439," Dorsey said. It is not meant to be used for visits to discuss the results from the AWV.

Question 5: If a physician performs the AWV or IPPE, must that doctor be a primary care physician? Or can any specialist (gynecologist, neurologist, etc.) collect for these services?

Answer: "In the regulations for health professionals, we define a physician as a doctor of medicine or osteopathy, so an MD or DO," said CMS's Jamie Hermanson during the call. The physician's specialty does not matter, she said.

HRA Is Required for Annual Wellness Visit

Question 6: Is the health risk assessment (HRA) a required component of the AWV, and if so, does it have to be done annually as well?

Answer: "The statute requires that the HRA be included and taken into account" during the AWV, Hermanson said. "During the subsequent visits, the HRA would need to be updated, she added.

In addition, Frilling noted, if the physician has to help the patient complete the HRA (for instance, if the patient did not complete it before the visit), you cannot separately report the doctor's time doing that, because it's already included in payment for the code.

Question 7: If a patient never had an IPPE/WTM exam, is he still eligible for the annual wellness visit, or is the IPPE required first?

Answer: "A patient does not need to receive an IPPE in order to be eligible for the annual wellness visit," Hermanson said. "To be eligible for the AWV, they just need to have Medicare Part B for longer than 12 months," after which they are eligible every year for subsequent annual wellness visits."