Wiki Medicare Annual Wellness Visit and Annual Physical Visit

[jbhuju]

hello,
can we bill MAWV (G0438/G0439) and Annual Physical (9939X) code together on same claim? if yes what are requirements? please help.
thank you

 

[CBLENNIE]

Medicare, and most Medicare Advantage plans do not cover the preventative E&M codes in the range of 9938x & 9939x. If you bill them both on the same claim to Medicare or an MA plan mostly likely the 9938x or 9939x code is going to be denied.

The question is will it be denied as patient liability or provider liability, which I don't know because I work in commercial insurance and only know a little bit about excluded services, is whether this service requires an ABN to force the service to be patient liability rather than provider liability. Maybe someone else will come along and answer that question, unless you already know the answer to it.

 

[Pam Warren]

an ABN is not required for a categorically excluded service such as the annual physical 9939x. It would be patient responsibility. However, we are expected to adjust the amount of the covered service from the amount of the non-covered service and the patient is responsible for the balance.
Preventive Medicine Carve Out:

Claims Processing Manual: 30.6.2 - Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service (Rev. 1, 10-01-03)

See Chapter 18 for payment for covered preventive services. When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a noncovered preventive medicine service (CPT codes 99381-99397), consider the covered visit to be provided in lieu of a part of the preventive medicine service of equal value to the visit. A preventive medicine service (CPT codes 99381-99397) is a noncovered service. The physician may charge the beneficiary, as a charge for the noncovered remainder of the service, the amount by which the physician’s current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit. Pay for the covered visit based on the lesser of the fee schedule amount or the physician’s actual charge for the visit. The physician is not required to give the beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit. However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury. There could be covered and noncovered procedures performed during this encounter (e.g., screening x-ray, EKG, lab tests.). These are considered individually. Those procedures which are for screening for asymptomatic conditions are considered noncovered and, therefore, no payment is made. Those procedures ordered to diagnose or monitor a symptom, medical condition, or treatment are evaluated for medical necessity and, if covered, are paid.