Coders: Annual Wellness Visit--Read the Guidelines!!

Pam Brooks

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I have seen many threads on this topic that worry me...

Coders, I urge you to make sure you carefully read the MLN Matters MM7079 and the related CR Transmittal R134BP and R2109CP.

I see a lot of you using the words "Annual Physical", or "Preventive Physical". The Annual Wellness Visit is not a head-to-toe physical exam. This is a risk assesment to help physicians put together a patient-specific plan for preventive care. Physicians need to know exactly what criteria are expected for this high-RVU visit. It's up to us, as certified coders to make sure our physicans have the tools and information they need so that they can complete this visit with the appropriate documentation. Believe me, Medicare is going to be auditing this.

The press has erroneously reported that Medicare is now paying for preventive physicals or preventive exams, and our Medicare population is going to be calling your offices, asking for their 'free physical'. Based on the criteria for this covered service, the only objective portion of this encounter is the gathering of vitals. Let's not compound the problem by using the wrong language when describing these services. It will be up to us to educate the patients and our providers that this is not a physical exam, as would be reported by codes in the 99381-99397 range.
 
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Annual Wellness Visits

Thanks for your information Pam.

What is your opinion to using this new code "G0438 and the G0439 along with the G0101 on the same days visit; and could you use a modifier?? Will the providers have to do these on separate visits to be sure they are reimbursed correctly?
Also, any type of sick visit I would guess we could use the modifier 25 on say a 99213 on the same day as a G0438 or G0439 if this should happen to take place on the same day?

Any coder's input would be appreciated! Thanks CP
 

LindaEV

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Thanks for your information Pam.

What is your opinion to using this new code "G0438 and the G0439 along with the G0101 on the same days visit; and could you use a modifier?? Will the providers have to do these on separate visits to be sure they are reimbursed correctly?
Also, any type of sick visit I would guess we could use the modifier 25 on say a 99213 on the same day as a G0438 or G0439 if this should happen to take place on the same day?

Any coder's input would be appreciated! Thanks CP
You can use the G codes on the same day (no modifier needed). Also applies to a sick visit...and yes you would add a -25 on that one.
 

Lisa Bledsoe

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I have seen many threads on this topic that worry me...

Coders, I urge you to make sure you carefully read the MLN Matters MM7079 and the related CR Transmittal R134BP and R2109CP.

I see a lot of you using the words "Annual Physical", or "Preventive Physical". The Annual Wellness Visit is not a head-to-toe physical exam. This is a risk assesment to help physicians put together a patient-specific plan for preventive care. Physicians need to know exactly what criteria are expected for this high-RVU visit. It's up to us, as certified coders to make sure our physicans have the tools and information they need so that they can complete this visit with the appropriate documentation. Believe me, Medicare is going to be auditing this.

The press has erroneously reported that Medicare is now paying for preventive physicals or preventive exams, and our Medicare population is going to be calling your offices, asking for their 'free physical'. Based on the criteria for this covered service, the only objective portion of this encounter is the gathering of vitals. Let's not compound the problem by using the wrong language when describing these services. It will be up to us to educate the patients and our providers that this is not a physical exam, as would be reported by codes in the 99381-99397 range.
You are absolutely correct Pam! These new "services" are not physicals in any way shape or form. The only "hands on" required are vitals.
 

Pam Brooks

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Thanks for your information Pam.

What is your opinion to using this new code "G0438 and the G0439 along with the G0101 on the same days visit; and could you use a modifier?? Will the providers have to do these on separate visits to be sure they are reimbursed correctly?
Also, any type of sick visit I would guess we could use the modifier 25 on say a 99213 on the same day as a G0438 or G0439 if this should happen to take place on the same day?

Any coder's input would be appreciated! Thanks CP
Our contractor NHIC hasn't yet come out with the guidelines for those scenarios....in fact, we're still waiting for our 2011 preventive care criteria!

Because the G0101, G0102 and Q0091 are 'separately identifiable' from the G0438 and
G0439, I anticipate that we will be able to bill them as long as we appent the -25 on the
G0438/9.

What I do know about billing the E&M at the same time (i.e 99213) is that the documentation criteria for the AWV includes a great deal of PFSH, and we would not be able to double-dip to use that information to also support an E&M. Basically, anything covered in the AWV could not be considered in a separate E&M...which might limit our higher-level E&M visits. We couldn't count vitals as part of our E&M exam, for example.
Although CMS might not come out with crystal-clear guidlelines regarding these new codes, we can pay attention to the guidelines that are currently in place and use them accordingly for this circumstance.

Pam
 

dawnsilva

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annual wellness visit

according to the Medicare Claims Processing Manual Chapter 12, section 30.6.1.1 under 2. Annual Wellness Visit, it states "allows for a preventive physical exam, called the annual wellness visit".
 

dawnsilva

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Not quite sure how is it a contradiction if this is what CMS is stating the wellness visit is?
 

brake

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annaual Wellness forms or checklist

I'm trying to educate my providers and staff; are there any forms or checklist to prompt questions to the patients from the providers so the documentation will be correctly indentified by the criteria? Thanks


Chiquita S. Brake,CPC
 

pglazener

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I just want to clarify to make sure I understand the new codes.

If a patient has had their IPPE and is an established patient with a doctor, we would use G0439 for their subsequent AWV as long as it's 12 months after the IPPE.

If a patient has had their IPPE with another doctor and comes to our practice at least 12 months after the date of their IPPE, we would use code G0438.

Is this correct?
 

Pam Brooks

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Not quite sure how is it a contradiction if this is what CMS is stating the wellness visit is?
Well, your previous post pointed it out. "preventive physical exam" which is an Annual Wellness Visit.

In reading the criteria for the AWV, there's precious little exam component.

I didn't intend to incite an argument, just suggested that everyone use the language that will be most clear to our patients and providers.
 

Pam Brooks

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I'm trying to educate my providers and staff; are there any forms or checklist to prompt questions to the patients from the providers so the documentation will be correctly indentified by the criteria? Thanks


Chiquita S. Brake,CPC
I can send you the FAQs I prepared for my providers and our patients. I also have a checklist for the guidelines.


Send me a PM, with your email, and I'll be happy to get that to you.

Pam
 

margie513

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Good Afternoon Ms. Brooks
Is there any way that you could share your FAQs for the provider and patient as well as your checklist for the guidelines. I'm trying to provide my physicians with a better clarification on this new Annual Wellness Visit. I would really appreciate it.

Margie Delgado
mdelgado@norwalkmedgroup.com

Thank you in advance
 

vickibrown

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You can use the G codes on the same day (no modifier needed). Also applies to a sick visit...and yes you would add a -25 on that one.
I have just received my first EOB from Medicare for 2011 whick I billed E/M visit with the AWV. Medicare has paid the OV and denied the AWV due to non covered services because this is a routine exam done in conjuction with a routine exam. Modifier 25 was added to OV code. Would we also add another modifier to the AWV? Desperate help needed, we have done 175 of these exams.
 

cheermom68

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Awv

In a teleconference from NGS yesterday, we were told to hold these claims until 4/4/2011 because that is the implementation date. They said that if you bill them now they should be paid but would not be tracked properly until 4/4. They also stated that if you use V70.0 for dx it would be denied. They could not give an appropriate dx however. They said that they were going to try to get there systems to accept the V70.0 when billed with these codes and would let us know if and when they did. They highly advised holding these claims until 4/4.

LeeAnn
 

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No, G0438 is not dependent on the Welcome to Medicare IPPE visit. That is not an annual benefit. The
G0438 is used for the First Annual Wellness Visit- Other than the mandatory time lapse, it doesn't matter if the patient did or did not have the IPPE. The G0438 is used the first time the patient takes advantage of the annual wellness visit. Every year after that, the G0438 will be used to indicate that it is a subsequent wellness visit and that the first annual wellness visit has been performed - by your office or another. That is not a factor.
 

MMAYCOCK

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No, G0438 is not dependent on the Welcome to Medicare IPPE visit. That is not an annual benefit. The
G0438 is used for the First Annual Wellness Visit- Other than the mandatory time lapse, it doesn't matter if the patient did or did not have the IPPE. The G0438 is used the first time the patient takes advantage of the annual wellness visit. Every year after that, the G0438 will be used to indicate that it is a subsequent wellness visit and that the first annual wellness visit has been performed - by your office or another. That is not a factor.
 

MMAYCOCK

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LeeAnn,

I'm really curious to hear if providers were allowed to respond to NGS" instructions to hold these claims until April? Were they allowed to give feedback?

Melanie
 

cheermom68

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Feedback

They did not allow questions or feedback, but gave the e-mail for support to send questions.
They pretty much just read the powerpoint that stated the guidelines.
LeeAnn
 
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CMS does refer to the AWV as a preventive exam. It's stated twice:

Annual Wellness Visit (AWV)

Effective January 1, 2011, Section 4103 of the Affordable Care Act (ACA), allows for a preventive physical examination, called the annual wellness visit (AWV), and includes personal prevention plan services (PPPS). The AWV is a new annual Medicare preventive physical examination, available for eligible beneficiaries, and identified by new HCPCS codes G0438 (Annual wellness visit, including PPPS, first visit) and G0439 (Annual wellness visit, including PPPS, subsequent visit).


http://www.cms.gov/Transmittals/downloads/R2109CP.pdf
 

mitchellde

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I have gone over this with the fine toothed comb so to speak and sat with a physician while we went over the requirements and role played out the visit. There is no way to accomplish all of the requirments with merely vital signs. The provider must examine the patient to determine if there is evidence of any cognitive imparement, or to review for functional ability. While they have specifics that must be documented to meet the objectives, in order to document these things the provider needs to perform certain examinations. I am not totally comfortable with telling the provider that this is not a preventive examination, that it is vitals only. I think this is an incorrect message, and also we must remember that the patients were told by Medicare they would pay nothing for preventive services after january 1 2011. To use the AWV as a vital signs only and then reschedule the patient for the preventive encounter is going to be an issue, if you try to bill this as preventive, Medicare will deny it and the patient will be responsible which will cause great concern with these patients, or to reschedule a preventive and bill it as a level 4 or 5 encounter to have Medicare pay for it is potential for fraud. I agree with the above.. AWV is a preventive EXAMINATION encounter.
 
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Great post Debra!

Also...on another thread here (under general Medicare discussions I believe), there is a quote from a person at CMS who stated that the AWV is intended to be a continuation of the IPPE, even though the words "physical exam" were not specifically mentioned.

Providers I've talked to agree with your thoughts that it would be difficult to do the AWV without examining the patient.
 

Jewel

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G0438-G0439: Screening diagnostic tests

What are the specific "screening labs” entitiled under these visits? It has not been clarified what those labs are (Welcome to medicare allowed for EKG and US abdomen if history of AAA). Has anyone found the reference regarding the above? Thanks in advance :eek:
 

Pam Brooks

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I have gone over this with the fine toothed comb so to speak and sat with a physician while we went over the requirements and role played out the visit. There is no way to accomplish all of the requirments with merely vital signs. The provider must examine the patient to determine if there is evidence of any cognitive imparement, or to review for functional ability. While they have specifics that must be documented to meet the objectives, in order to document these things the provider needs to perform certain examinations. I am not totally comfortable with telling the provider that this is not a preventive examination, that it is vitals only. I think this is an incorrect message, and also we must remember that the patients were told by Medicare they would pay nothing for preventive services after january 1 2011. To use the AWV as a vital signs only and then reschedule the patient for the preventive encounter is going to be an issue, if you try to bill this as preventive, Medicare will deny it and the patient will be responsible which will cause great concern with these patients, or to reschedule a preventive and bill it as a level 4 or 5 encounter to have Medicare pay for it is potential for fraud. I agree with the above.. AWV is a preventive EXAMINATION encounter.
Ah, I can always count on you ....! LOL

I agree, from a physician's perspective, they must examine the patient in order to determine cognitive defects, etc. but in considering the exam bullets in our audit tools, there are few instances where an exam of any detail would take place, for most patients.

Overall, there is currently no requirement to do a head-to-toe exam, but in order to satisfy the psychiatric and functional elements of the AWV, the provider may have to do some of the examination elements, based on the patient's risk assesment. The only straightforward hands-on exam requirements (from an auditing perspective) specifically for the AWV are the vitals. For those providers using an EMR (such as mine), we have built specific templates to satisfy all of the AWV critiera; and in order to be able to provide this service in a timely manner, we excluded our standard Pe template, with the exception of the vitals. Of course, in order to meet the criteria as required, an examination in some form would take place, which we do allow them to document, but we did this within the confines of our customized template, and not as part of our standard Preventive physical. Thinking outside the box, as I have to do in the EMR world, we had to exclude our standard Pe template in order to have time and space to capture all of the required data.

This is what I wanted to convey...that from a workflow perspective, it could get cumbersome to also document a head-to-toe, if it's not medically necessary. My doctors (Just our 45 primary care providers) fully understand the requirements of the AWV, and would not assume that they shouldn't 'examine' the patient in order to assess their risk.

We also have to be very careful that we are not giving the wrong message to our patients, by giving them a blanket statement that preventive examinations are covered. In their minds, they might expect a hands-on, head-to-toe exam, and then will be annoyed if that's not what we provide. We did create a patient FAQ specifically to address this, but CMS has a very nice informative brochure that you certainly could all provide to your practices.

For those of you that continue to have questions, you really should contact your local contractors. Some contractors seem to be handling this differently, and I can only speak to what I've learned from NHIC. There is much information on the CMS website, which we should all have in our "Favorites", and we have to make the best decisions for our providers regardless of what other coders (including myself) have done for their practices.
 

rthames052006

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No, G0438 is not dependent on the Welcome to Medicare IPPE visit. That is not an annual benefit. The
G0438 is used for the First Annual Wellness Visit- Other than the mandatory time lapse, it doesn't matter if the patient did or did not have the IPPE. The G0438 is used the first time the patient takes advantage of the annual wellness visit. Every year after that, the G0438 will be used to indicate that it is a subsequent wellness visit and that the first annual wellness visit has been performed - by your office or another. That is not a factor.
The subsequent visits should be billed with the procedure code G0439.
 

deut649

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AWV questions

my docs have questions about this, which i have been unable to get from the website and I have left messages for Medicare to call me back. when they say one AWV a year is it 365 days (exactly) or if they have a AWV in January can they have a subsequent on the next January? My doc wants this in writing from them....Where can I find this?
On the MLN pertaining to the AWV it states effective January 1 2011, implementation date of April...what does the implementation date stand for. Any Help is appreciated.
 
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Usually "Once a year" is pretty clear. Does your Dr not understand the concept of time?
I mean come on really? Stand up and tell him. One yr equals 365 days Doc. Schedule the pt back on the 366th day. Issue closed.
I would approach a situation like this as follows:
It's your practice Dr., the guidelines for the AWV clearly state one per yr.
I am advising that you do not schedule any more than that.
 

Pam Brooks

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Usually "Once a year" is pretty clear. Does your Dr not understand the concept of time?
I mean come on really? Stand up and tell him. One yr equals 365 days Doc. Schedule the pt back on the 366th day. Issue closed.
I would approach a situation like this as follows:
It's your practice Dr., the guidelines for the AWV clearly state one per yr.
I am advising that you do not schedule any more than that.
LOL....I needed a laugh this morning......This is why we'll always be employed!

I was once told by a physician colleague (who is also a certified coder) that his CPC exam was far more challenging than his medical boards.

Enough said. Keep up the good work everyone!
 

susiekay

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Decision Health has an encounter form on their website that you can print out and use for the new wellness visit, G0438 & G0439
 

sbates

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I was able to locate some very comprehensive paperwork on the AAFP website if your physicians have membership/access which states at the bottom may be photocopied or adapted for use by physicians in their own practices. If you don't have access try http://www.aafp.org/fpm/20110100/p22.html to possibly get straight to the forms.
 

coppercent

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G0438 and G0101

:(I billed these without any modifiers and the G0438 was denied. Would I use -25 or -59? Is G0438 considered an E&M or procedure? If a modifier is needed, then why isn't it listed in the NCCI edits??? Thanks :confused:
 

annielou

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Awv

That sounds correct. Our doctors, after I gave them the guidelines, have adhered very well to covering and documenting everything required by the AWV guidelines. I did have to reiterate that if they bill for an E/M at the same time, they cannot use a combined ROS, vitals, etc for both codes. Generally they are providing the AWV when the patients come in for a thorough annual review of their medical problems, so, after reviewing the notes, i often go back to the docs and have them downcode the E/M so that they aren't counting some of the requirements twice, even though they are only documented once. We have been doing a lot of these AWVs and I think it is good for the doctor and the patient to have them reflect on their wellness care; what has been done already and what needs to be done in the future. The revenue is good and I believe the intention of Medicare to make sure our patients are keeping up with their wellness needs is a good thing. We are a family practice, by the way.
 

kjiang

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Complete Physical Exam

Are hearing screening and visual screening part of CPE or separately billable? Are there written guidelines available?

thank you for your input
 

maschneck

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We had Medicare and Wellcare Medicare come to our office and explain the policies on the G codes and office visits. They said, that if the doctor does an E/M visit with the G code, use a 25 mod on the G code and the E/M code. However, you need to be sure to put any V codes with the G code (ie. G0439) and the diagnosis codes on the E/M code.
 

dkbilling

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Mcr awv

I am undestanding that there should be something such as the Beck's depression screen used to glean the risks for depression. Shouldn't that document then be part of the medical record for the date of service of the AWV? Darlene Billing, CPC
 
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