Wiki AWV and Prev code for MA plan

[myinnerchild]

Hi there, can someone please point me in the right direction on how to properly educate a medical director regarding the use of G0438/G0439 and a 9938X code on a same day visit. I believe there are very specific points of documentation that must exist in order to satisfy the submission of both codes on the same date of service. He is stating that due to Medicare not covering the 993 code, we can streamline the requirements because they wouldn't be flagged for audits. I am still relatively new to coding and not sure how to fully explain that I don't believe this to be true other than my gut says no. For context, we are developing an incentive program and he wants to additionally incent a provider to submit both codes. Help!!!!

 

[thomas7331]

First of all, CPT & HCPCS codes have specific definitions, and those definitions don't change simply because Medicare or any other payer doesn't cover them or doesn't audit them. So you can't 'streamline' those definitions by performing a service that doesn't meet the definition but still use the code.

Second, if I'm understanding you correctly, if you're just going to do this for patients who don't have coverage for a particular code then you're basically saying that for your patients who are going to self-pay for a given service, you're going to provide them a reduced service but still charge the full amount. Now patients aren't coders, so they probably would be unlikely to understand that this was happening, but even so, what kind of customer service would this be? I'll be a little blunt here, but I think it's kind of like taking a payment and giving the customer less than the correct amount of change and hoping they don't notice. Just ask your medical director what he would think of any other business that did such a thing.

Your gut instincts are correct, and the best practice is to treat all patients and payers the same. Not only is it the more compliance practice, but it's the best for business - to do otherwise, your providers can may spend more time trying to figure out who to charge what, which can end up costing more than they save.