Know the Circumstances in Which G0444 May Apply
Question: An established 70-year-old Medicare patient presents to a family medicine office for a routine follow-up of stable hypertension. The patient has no current depression diagnosis and is due for an annual depression screening. A nurse administers a standardized screening instrument, reviews the responses, and records the score. The screening and review take 14 minutes. The practice has staff-assisted systems in place for diagnostic evaluation, treatment, and follow-up if the result is positive. Would a HCPCS Level II code be appropriate here to describe the screening or should it be considered part of the encounter? Codify Subscriber Answer: Report G0444 (Annual depression screening, 5 to 15 minutes). According to national coverage determination (NCD) 210.9, Medicare covers this service once every 12 months when it is furnished in a primary care setting that has staff-assisted depression care supports to ensure accurate diagnosis, effective treatment, and follow-up. The Centers for Medicare & Medicaid Services (CMS) does not require a particular screening instrument, but the record should identify the screening instrument used, the results or score, and any indicated follow-up or plan of care. The nurse performing the screening doesn’t prevent you from billing G0444 if they’re under physician or nonphysician practitioner (NPP) supervision. In this scenario, the service meets the code’s 5- to 15-minute description, as well as the Medicare setting and support requirements. You should only report G0444 if the documentation supports a distinct, annual screening service — and 11 full months have passed since the previous screening. Reporting this code because depression symptoms are discussed within the realm of an evaluation and management (E/M) service, without meeting the other coverage criteria, wouldn’t be appropriate. For more specifics on billing instructions, look to the Medicare Claims Processing Manual, Chapter 18, Section 190. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC 
