Wiki G0439 + e&m?

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Cher91600

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My last office was Opted Out of Medicare, and the G0438/G0439 codes were created during that time. Now my in-network doctors are coding the G0349, but always coding with an E&M. Is that standard protocol? From what I can find G0349 is a stand alone code for the "wellness visit" The notes have a Health Risk Profile listing + standard preventive orders (ei: mammogram, colonoscopy etc), but also has a full ROS & EXAM.

I just want to make sure I'm sending these visits correctly, as everything I read says CMS watches these codes closely.

Thank you in advance for any guidance.
 
The documentation must support each code, so look for a note that supports a separate E&M with a separate problem. Most Medicare patients have chronic conditions that require following, but performing them during a MCR wellness visit is a challenge. I point to the CPT guidelines that outline the preventative to help physicians understand what are good indications that may support that separate E&M. A trivial or minimal problem without additional workup will not support a separate E&M service.

The wellness visits have all kind of points they need to hit and if they don't have a template to work from, something will get missed.
 
g0439 + e&m

Cher91600, I agree with OCD_coder. This is a battle I have fought many times.

What I explain to my providers/clients is: If it is a simple, quick, easy, non-life threatening issue, then "just do it" and consider it included with the G0439. As OCD_coder pointed out, it's highly unlikely a Medicare patient isn't going to have "something" that is chronic and needs following. Therefore, I could easily see a provider fall into the mindset of "every Medicare wellness visit = 2 visits! yay for me!"

If the complaint is serious and needs immediate attention, tests, etc. then that justifies the separate E&M "so long as it is medically necessary" and the documentation supports both the G0439 and the E&M. I would expect this scenario to be the exception, not the norm.

If the complaint is something that is chronic but has had some changes/exacerbations, etc., and does not clinically require immediate attention then I suggest the provider say "let's have you come back for a visit for "x" so I can dedicate my full attention to "x"." That way they bill the G0439, are better able to stay on schedule, the patient knows the issue is going to be looked at, and the provider still gets to bill both the G0439 and an E&M (but without increasing the possibility of your MAC asking for chart notes, doing an audit, etc. for both done the same day).

Hunter Smith, CPC
 
Thank you both so much. That was what I had thought. The doctors struggle with understanding Mod-25's in general, but I was starting to question my understanding of the guidelines when I was seeing the doctors billing the codes together nearly 100% of the time. I have a big coding refresher meeting set up & this will definitely be on my list. :)
Thanks again!
 
I'm glad this topic was brought up, as I have seen the same thing and all boils down to provider education. But before that can be done, we MUST know the guidelines and the rules and hold the line! Not always easy to do!
 
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