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nikki3

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DIAGNOSIS CODE FOR MEDICARE WELLNESS G0438 BEEN GETTING DENIALS. ALSO ANYONE HAVE A MEDICARE WELLNESS CHEAT SHEET FOR CPTS WITH DIAGNOSIS. BEEN GETTING DENIALS TRYING TO CORRECT THEM:confused: TIA
 
We use V70.0 for our diagnosis for G0438 and G0439, have had no problems with it. If your G0438 or G0439 is being denied for any other reasons, it maybe because G0438 was already billed, and G0439 needs to be billed next.. Or if you are billing the G0439 and its been less than a year since the last exam that also could be a reason.. What exactaly is your denial saying?
 
Also, if the patient is new to medicare, the G0402 needs to be billed first before G0438 as that code is the first annual medicare wellness exam within the first 12 months of coverage.. You would need to check out the Medicare cards first to make sure you see the start of the patients coverage.
 
marymessina1998@yahoo.com said:
Also, if the patient is new to medicare, the G0402 needs to be billed first before G0438 as that code is the first annual medicare wellness exam within the first 12 months of coverage.. You would need to check out the Medicare cards first to make sure you see the start of the patients coverage.
Click to expand...

See, we had a PR-119 denial for a G0438, and it looks like this beneficiary is eligible for both an initial AND subsequent AWV according to their Preventive Services eligiblity. I did not see a G0402 billed anywhere there unless of course the G0438 (or a possible G0402) was billed under another provider. Would it be possible to have a claim denied due to a beneficiary not having a G0402 previously billed before their G0402? I think I would see a different reason code?
 
mmutterperl said:
See, we had a PR-119 denial for a G0438, and it looks like this beneficiary is eligible for both an initial AND subsequent AWV according to their Preventive Services eligiblity. I did not see a G0402 billed anywhere there unless of course the G0438 (or a possible G0402) was billed under another provider. Would it be possible to have a claim denied due to a beneficiary not having a G0402 previously billed before their G0402? I think I would see a different reason code?
Click to expand...

Hello,

Not sure if you are still looking for an answer on this one, but here goes:

You can still bill a G0438/G0439 even if a G0402 was never billed for the patient. Special timeline rules apply for all three codes:

  • G0402 - Beneficiary is eligible the first 12 months of Medicare coverage. A one-in-a-lifetime EKG procedure may also be billed out, if appropriate and performed.
  • G0438 - May be billed out after 12 months of Medicare coverage, this is a one-time benefit.
  • G0439 - Can be billed 12 months after either a G0438/G0439 have been performed and billed out. Some MACs allow 11 months inbetween visits so I would double check your local MAC. If G0439 was billed out before any G0438 and paid (perhaps by a different provider), then the G0438 benefit has been lost. There are ways to look up and check whether the patient has been billed AWVs, but only works for Original Medicare and perhaps some MACs. This gets tricky when the beneficiary has a Part C coverage, as their reports don't always communicate with each other.

Sources:

CMS ABCs on IPPE
CMS ABCs on AWVs
Noridian (my local MAC) on IPPE and AWVs

Hope this helps!
 
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