Part B Insider (Multispecialty) Coding Alert

Reader Question:

Bypass Medicare AWV Blunders With Handy Insight

Published on Fri Feb 11, 2022

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Question: There are nuances in Medicare Part B billing that still confuse me — and sometimes cause denials. For example, at a beneficiary’s annual wellness visit (AWV), the provider administered a flu shot and a depression screen. Our practice billed G0439, G0008, 90471, G0444, and 96160 and got denied on the 90471 and 96160. What did I do wrong? Should I have used modifiers for the flu shot and depression screens? And should I have used 96127 instead of the 96160?

Vermont Subscriber

Answer: Part of the problem with your coding for this encounter lies in using both Medicare G codes and CPT^®codes for the same procedures. For Medicare claims, only the G codes are needed.

First, assuming this was not the patient’s initial Medicare AWV, you have correctly reported G0439 (Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit).

However, for the flu shot, you cannot report both G0008 (Administration of influenza virus vaccine) and 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) together, as the codes describe the same service. For a Medicare patient, you should report only G0008 plus the appropriate CPT^®code for the influenza virus vaccine administered, such as 90662 (Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use).

Code G0444 (Annual depression screening, 15 minutes) appropriately describes the depression screen you mentioned and is the code of choice when reporting depression screening for a Medicare patient.

Bundling alert: For subsequent Medicare AWVs, G0444 does not bundle into G0439, meaning that you can report the depression screen separately and without a modifier. However, G0444 does bundle into Medicare’s initial AWV, coded using G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit), and the “Welcome to Medicare Visit,” coded using G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment). In these cases, you cannot separate the services (i.e., no modifier is permitted to override the corresponding National Correct Coding Initiative [NCCI] edits), and you cannot separately report G0444.

The 96160 (Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument) denial is probably due to the NCCI edit that bundles 96160 into G0444 when reported together without a modifier. If you intended to report only the depression screen, then G0444 is sufficient. If you intended to report a health risk assessment in addition to the depression screen, then you should add an appropriate modifier such as 59 (Distinct procedural service) to 96160 to override the NCCI edit that otherwise bundles 96160 into G0444. An AWV already includes a health risk assessment.

Last, you should not substitute 96127 (Brief emotional/ behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument) for 96160. As noted, 96160 is for administration of a patient-focused health risk assessment while 96127 is more specifically for a brief emotional/behavioral assessment such as a depression inventory. Code 96127 is more specific than 96160 and should be used when the assessment instrument relates to the domains described. In this case, you have already captured the depression screen using G0444.