Wiki Medicare physical and documentation issue

[leren44]

I have a physician who is charging a Medicare patient for a G0439. The diagnosis provided are:encounter for screening for diabetes, encounter for screening for lipoid disorders, and screening for anemia. Z13.1, Z13.220, and Z13.0.
Also, there is no documentation in the noted of systems checked. I don't think G0439 is appropriate. I'm thinking and counseling code would be more accurate. Any thoughts?

Thanks for any input.

 

[coding4fun]

G0439

The IPPE Medicare codes as well as the Initial + Subsequent G codes are strictly for counseling purposes. You do not technically examine the patient for this service as you are providing counseling. Medicare has an article on their website outlining the areas which have to be completed before billing of this code can be done. You should also check the medicare site to make sure that they have not received this service elsewhere prior to billing.