Can you bill an AWV if Medicare is the secondary payer?

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Good Morning,

If a patient has a primary PPO plan that does not cover AWV but has Medicare secondary; can you bill the Annual Wellness Visit to the primary insurer even though you know it is a non-covered benefit? Also, does anyone know if Medicare will pay the AWV if primary denies? Any guidance would be greatly appreciated.

I have reviewed this cheat sheet but it did not clarify: http://www.cms.gov/MLNProducts/downl...Fact_Sheet.pdf).
 

CodingKing

True Blue
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I would think it better to do the full physical if its no cost share under the primary. AWV is very limited in scope compared to a full exam.
 
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I found this from my local MAC:
"Q. How should an AWV be coded if Medicare is the secondary payer? If the primary payer denies it as a non-covered service, we receive a denial from Medicare. Should we bill a G0438 even though a private sector commercial carrier is the primary insurance?

A. Medicare understands not all other payers recognize all Medicare specific codes. Submit the appropriate code that would be equivalent to the primary payer and make the appropriate code change for Medicare. If you submit the G0438 and receive a denial from the primary payer, you can go through the Medicare appeals process."

I'm slightly confused with the "make the appropriate code change for Medicare" portion, but there is no further elaboration.

I DO know that if you bill a preventive visit, such as 99397, Medicare will NOT pay anything because the services included in a preventive visit go above and beyond what's included in an AWV.

However, it's important to remember that preventive services are typically at no cost to the (non-Medicare) patient. See https://www.healthcare.gov/preventive-care-adults/

If the patient has a PPO plan that requires free preventive care services per the above mentioned law, there would be no OOP expenses, hence there would be nothing left to bill Medicare for.
 
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