Preventive visit (99396) and Medicare's AWV (G0438/G0439)

[mamon]

A patient came in for a preventive visit in 2018; code 99396 was billed out to his commercial insurance. His coordination of benefits was recently updated (his Medicare is now primary for DOS) and the commercial insurance then recouped the payment earlier this year, so we billed the patient for it, but the patient says to bill Medicare.

As far as I know, we can't change the code to G0438/G0439 and Medicare does not pay for 99396, so I think it's patient responsibility. Am I correct in this?

 

[mullman]

You cannot charge the AWV unless all documentation guidelines are met. If they are, you could bill it. However, since he was not there for an AWV they likely are not present. I assume he did not sign an ABN since you did not know he had MCR primary. Since preventative wellness visits are not a covered service by Medicare, he would ultimately be billed if AWV is not suitable for billing. I think the patient is stuck with this one.