Wiki G0136 Being Denied by Medicare

[BillingAMC]

Can someone please assist? G0136 is being denied by Medicare. I am using appropriate DX's such as Z59.89 (housing and economic circumstances), Z60.8 (other problems related to social environment) and it is getting denied. I tried adding a 33 modifier and it still was denied. Can anyone give some advice? Thanks!!!

07/01/2024 - 07/01/2024​	​	HC:G0136​	$25.00​	$0.00​	-​	PR-49: $25.00​
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Adjustment Group Codes​
CO​	:​	Contractual Obligations​	​
PR​	:​	Patient Responsibility​	​

Adjustment Reason Codes​
2​	:​	Coinsurance Amount​
45​	:​	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)​
49​	:​	This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.​

 

[sls314]

When did you submit the claim? It was implemented on October 7th, so if you submitted you claim prior to that it could be the reason for the denial.

You'd only use Modifier 33 if it were being performed in conjunction with an Annual Wellness Visit. Otherwise, you'd bill with no modifier and it would be subject to deductible/coinsurance.

https://www.cms.gov/files/document/mm13486-annual-wellness-visit-social-determinants-health-risk-assessment.pdf

 

[BillingAMC]

Thank you very much. I am checking the DOS now. It looks like most of them were from before that date. I will try to see if the physician will do one on an upcoming patient and see if that claim pays. I appreciate it very much!!

 

[sls314]

Thank you very much. I am checking the DOS now. It looks like most of them were from before that date. I will try to see if the physician will do one on an upcoming patient and see if that claim pays. I appreciate it very much!!

I believe you can still bill it for DOS starting 1/1/2024, but due to the delayed implementation the claims had to be held until October 7th.

It could be worth trying to get that July DOS reprocessed if the claim was submitted before October 7th and was rejected in error.

Update us on whether you have success with that - I'm sure there are others here who would want to know if the claims were finally starting to get paid!

 

[kmdnine]

Does the provider include a statement differentiating the time of the E&M from the screening? Our providers include something like, "I spent an additional 15 minutes over and beyond the usual time for the physical exam performing ..." (whatever it might be) Maybe try to find a diagnosis or a screening code to put in front of the problems with Z codes.

 

[Saran8791]

Can we code G0136 FOR BCBS-MD.I am repeately getting denied

 

[Papitha]

Can we code G0136 FOR BCBS-MD.I am repeately getting denied

As per the CMS guidelines, yes, We can code. However, if there is some payer specific instructions, please check as it is repeatedly getting denied

 

[Papitha]

FYR,

• Frequency Limit: The service can be billed no more often than once every six months per patient per physician.
• Accompanying Services: G0136 must be billed in conjunction with an accompanying service, such as:
  • An Evaluation and Management (E/M) visit (including outpatient/office visits, hospital discharges, or transitional care management visits).
  • A behavioral health office visit (e.g., CPT 90791, 96156).
  • An Annual Wellness Visit (AWV).
• Documentation Requirements:
  • Document the patient's specific SDOH needs and which standardized tool was used.
  • Record the time personally spent on the assessment (5-15 minutes).
  • The medical record should reflect that the results of the assessment were taken into account in the patient's medical decision-making, diagnosis, or treatment plan, and an appropriate follow-up or referral was made.
  • Include relevant ICD-10 Z-codes (Z55-Z65) to document the identified social needs.
• Cost Sharing: If billed with an AWV, patient cost-sharing (deductible/coinsurance) is typically waived. If billed with an E/M or behavioral health visit, the usual Part B deductible and coinsurance apply.