Wiki Annual Wellness Exam versus Annual physical exam

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I have a question in regards to billing for annual examinations for patients that have had an annual examination within the past 12 months and the provider is billing out for Z00.00 or Z00.01 along with the CPT code for annual exams and the patient is withing the 12 month window. Is there reimbursement for this or will ir be denied as a CO97 or a CO18. I am asking this because I am getting push back from the providers at my place of work stating that it does not have to be billed once every 12 months, It can be billed more then one time within the 12 month window. Now according to all of the documentation that I have read an annual examination can only be billed every 12 months.

I also have a question in regards to billing an annual examination for a Medicare patient that is over 65. Those guidelines are a little blurry to me.

lledesma

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I am looking for clarification for Medicare replacement plans ( Humana, United Health Care AARP...) They allow for an Annual Wellness Exam G0438 and a Annual Routine Exam 99385-99387 or 99395-99397. I am trying to clarify what the difference is between these two examinations and can they be done and billed at the same time. I believe that the Annual Wellness exam is more reviewing family history, risk factors for depression, functional ability assessment, vital signs, cognitive impairment exam and establishing screening schedules for the next 5-10 years along with risk factor and preventive education. An Annual Routine examination is more hands on with a review of all systems and ordering any necessary testing based on the review of systems. Is this a correct assessment? and if so can they not be done at the same time reducing the need to have a patient have two different visits for routine examination?
 
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Help!

I would like some help with this also. I do know I have always seen Medicare state that G0438 is not an Exam and does not replace annual physicals exams. The G-Code is more of checking and making sure all the gaps are filled....preventative things and vaccines and such. But my director stated that "his provider would include that in with his annual physical exam and not bill separately for the services" my response is okay, but you are not on Medicare or Medicare Advantage program and if you were your PCP may bill for both services since it is allowed.
 
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cmercado0526

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Medicare created this mess!

The AWV, G0438/G0439, is not the same as an annual physical examination, 99397, but since Medicare calls this AWV monster a 'preventive' visit, patients don't know the difference and get extremely irate when billed for the physical exam. According to Medicare, E/M services may be billed separately using modifier -25 when separately identifiable. A 'periodic comprehensive preventive' exam is an E/M service. So, I don't see why they can not be done at the same visit. It just makes for a really long visit. And patients still won't have a clue why they are being billed for the 99397 part of it, the part Medicare does not cover.
 

CodingKing

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but since Medicare calls this AWV monster a 'preventive' visit, patients don't know the difference and get extremely irate when billed for the physical exam.

You really should be telling them the difference in advance, not after providing the services. I'd be irate too. You know its confusing so of course its even more confusing for a Medicare member. Medicare really needs to start requiring ABN for the true preventive exams.
 
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