# Denials for CPT's G0438 & G0439 - Is anyone receiving denials



## terri.carpenter@msj.org (Feb 7, 2013)

Is anyone receiving denials from Medicare when billing G0438 and G0439?  The denial code we are getting is CO97 which states "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated."  However we have called Medicare and the rep said it was related to the dx code V70.0.  Medicare had been paying these CPT's with dx V70.0 until December 2012.  Any information regarding this would be appreciated.


----------



## airart (Feb 9, 2013)

*Possibilities?*

Strange how they were paying before and now they are not since end of 2012.  These denials codes you are seeing "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated."  CO97 and B13 are not because of the diagnosis of V70.0.  That is the correct diagnosis in regards to billing the G0438 and G0439.

This was found on the WPS Medicare website Q&As regarding G0438 and G0439.

Question: 
Is there a specific diagnosis code required when billing for the AWV either initial or subsequent? 
Answer: 
Medicare does not have a specific required diagnosis code. Providers would use a preventive diagnosis code. 

Since there are no requirements for diagnosis code then you need to look at patient history of other possible providers having billed within the period allowed for such services.  

Billing Requirements:

1. The first yearly “Wellness” exam can't take place within 12 months of “Welcome to Medicare” physical exam.

2. G0438 or G0439 must not be billed within 12 months of a previous billing of a G0402 (IPPE), G0438, or G0439 for the same beneficiary. Such subsequent claims will be denied with a CARC of 119 (Benefit maximum for this time period or occurrence has been reached) and a RARC of N130 (Consult plan benefit documents/guidelines for information about restrictions for this service).

3. If a claim for a G0438 or G0439 is submitted within the first 12 months after the effective date of the beneficiary's first Medicare Part B coverage, it will also be denied as that beneficiary is eligible for the IPPE or “Welcome to Medicare” physical. Such claims with G0438 or G0439 will be denied with a CARC of 26 (Expenses incurred prior to coverage) and a RARC of N130.

Newest up to date info found for AWVs is this:

Claims received after initial claim has been denied – per MLN Matters MM8107 Editing Update for Annual Wellness Visit (AWV) 
 Related CR Release Date: October 26, 2012 	Effective Date: April 1, 2013 

CR8107 provides instructions for edits to be modified and only allow payment for either the practitioner or the facility for furnishing the AWV. Typically, when a preventive service is posted to a beneficiary's utilization history, separate entries are posted for a “professional” service (the professional claim for the delivery of the service itself) and a “technical” service (the institutional claims for a facility fee). 

However, in the case of AWV services, since there is no separate payment for a facility fee, effective for claims processed on and after April 1, 2013, the AWV claim will be posted as the “professional” service only, regardless of whether it is paid on a professional claim or an institutional claim. 

As a result of CR8107, Medicare Contractors will pay either the practitioner or the facility for furnishing the AWV, but only a single payment under the Medicare Physician Fee Schedule will be allowed for an AWV on the same date. That payment will be based on the first claim received.  

The claims following after the G0438 is paid, if the second claim is for the same date of service, the line item on the second claim is denied using a Group code of CO, instead of PR.  If G0439 claim is received and a G0438 or G0439 has been paid within the last 12 months, Medicare will deny the subsequent claim if the subsequent claim is for the same date of service, the denial will reflect a CARC of B13 (Previously Paid. Payment for this claim/service may have been provided in a previous payment.), a RARC N130 (Consult plan benefit documents/guidelines for information about restrictions for this service.), and a Group Code of CO.

I believe the CO97 you are seeing is really close to the B13 CARC denial.


----------



## bsesender (Jan 14, 2014)

*annual wellness*

so am i correct in the understanding that all patients must have been billed g0438 once before g0439 would be payable or are we supposed to be billing g0439 2012 and beyond??


----------



## Herbie Lorona (Jan 23, 2014)

I have not had any issues with billing these codes with diagnosis V70.0. There must be some other issue going on. Usually with a denial of CO97 there could be a good chance that code was already billed for that year. I would look into it more and find out what is going on. Usually if you call they will tell you what it is being included in? bsesender I don't believe G0438 has to have been billed in order to get paid for G0439. You can still bill G0438 after 2012.


----------



## karenwebb (Feb 21, 2014)

*any answers?*

I have seen V70.0 denying with Medicare quite frequently yet I"m not having any luck with a resolution. Anyone else have this issue or know how to solve it. Thanks.

Karen Webb CPC CANPC
kwebb@thebusinessside.com


----------



## Herbie Lorona (Feb 21, 2014)

What exactly are you billing and what is the denial you are receiving?


----------

