# Medicare Annual Well Visits



## Cole1971 (Jan 29, 2019)

Hello,
  I have a question in regards to what can be put on Claim sent to Medicare for the Annual Wellness Visits (G0402,G0438,G0439)

Is it appropriate to put diagnosis on the claim sent to medicare that are not attached to the G code or the E/M code for that claim? 
I hope this makes sense and thank you for your responses!


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## TThivierge (Feb 1, 2019)

*Medicare Wellness Exams*

Hi
If the patient gets wellness exam in which doctor or NP or PA  address another chronic illness/problem...this can be included as additional dx on the claim. However ensure link  proper Z00 dx code of wellness exam with the CPT 99381 till 99397  and G codes for Medicare payer .  If it is not documented by provider on that visit cannot put it down.


I hope this helps you

Lady T


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## Cole1971 (Feb 4, 2019)

*Annual Wellness Visits*

Thank you Lady T - Your response does help


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## Cole1971 (Mar 21, 2019)

*Medicare Annual Well visits.*

So, I was told by a doctor today that they do not need to document any of the diagnosis on the medicare annual wellness visit, that they are billing to medicare.
 They are simply pulling the top 12 or any 12 dx from problem list and billing them to medicare for the annual wellness visits, with no documentation.
The only dx code that i think should be on there is the Z00.00/Z00.01 am i correct in my thinking...

I am looking for documentation to take to compliance and the doctors of our facility. any help would be greatly appreciated
Thank you!!


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## kdlberg (Apr 3, 2019)

Cole1971 said:


> So, I was told by a doctor today that they do not need to document any of the diagnosis on the medicare annual wellness visit, that they are billing to medicare.
> They are simply pulling the top 12 or any 12 dx from problem list and billing them to medicare for the annual wellness visits, with no documentation.
> The only dx code that i think should be on there is the Z00.00/Z00.01 am i correct in my thinking...
> 
> ...



Here is a direct quote from our friends at MLN: "You must report a diagnosis code when submitting a claim for the AWV. Since you are not required to document a specific diagnosis code for the AWV, you may choose any diagnosis code consistent with the beneficiary’s exam."

So, no, you do not need to code with a Z00- code. However, what these providers are doing is not okay, because it does not really reflect what was addressed in the visit. If they were ever audited, they would be in a lot of trouble!

I would suggest that they document any chronic conditions that were addressed--even if it's a stable condition--and any new symptoms the patient is having, and use those as the code(s) for the visit.


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## Cole1971 (Apr 10, 2019)

*Medicare Annual Well visits.*

Thank you for your response K.  You have helped a great deal!!
Thank you, thank you 
N


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## Cole1971 (Apr 11, 2019)

*Medicare Annual Well visits.*

"I would suggest that they document any chronic conditions that were addressed--even if it's a stable condition--and any new symptoms the patient is having, and use those as the code(s) for the visit."

With the chronic and/or new conditions/ dx wouldn't the doctors be able to bill 99213-99214 with -25? In which, they would need more documentation and exam and ROS.


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## Pathos (Apr 11, 2019)

Hello,

The purpose of an AWV is an opportunity to perform a health risk assessment, go over the patient's chronic conditions, medication check, and manage screenings. The G0438/G0439 is a "hands-off" visit, meaning no physical exam is included. I know of some insurance carriers who offer an add-on code to include a Comprehensive Exam, but not every insurance has this yet.

While Correct Coding could possibly warrant an AWV + E/M, the lines between AWV and E/M are often muddled. Because the AWV reviews the patients chronic conditions and medications, the foundation (and thus the documentation) for adding an E/M + M25 has to be solid in order to prevent "double dipping" in the chart, meaning you cannot count the same elements for the AWV and also the E/M. Note that some insurances flat out deny if you try and bill both together, and want you to have two separate visits instead.

Remember, the AWV is not a problem focused visit like the E/M visit. So bringing up new problems/concerns at the AWV might not be the right place/time.

In short: Yes, you can do it but the provider needs to ensure solid documentation and medical necessity.


Hope that helps!


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## Cole1971 (Apr 12, 2019)

*Medicare Annual Well visits.*

Thank you Pathos,
 your information is helpful to me...I have a long road ahead of me with doctors, compliance and EHR.


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## dsmith612 (Apr 26, 2019)

*Next question on AWV*

The patient presents for their annual wellness visit.  Everything is completed but the provider notes that the patient is working harder to breathe.  After a workup the decision is made to send the patient on to the hospital as a direct admit for pneumonia.  The patient never indicated that anything was wrong and a the complete AWV was done.   Can the provider bill for both the AWV and the hospital admit?  Would you need a modifier?


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## ahaller0929 (May 23, 2019)

I believe the provider can bill for both the AWV and an E/M visit with modifier 25. However, both may not be paid. The guidelines state that if the patient has a problem that is addressed and requires significant workup you may report an additional E/M with the AWV. Just make sure that the provider has documented the medical necessity for the admit. Considering that the pt. never indicated anything was wrong could be problematic. Or it may indicate the pt. doesn't realize he's having a problem.


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## jhendrix08 (May 23, 2019)

I agree; you should be able to bill a low level E/M along with the AWV as long as the documentation supports it (ie, the breathing issue). Our providers have seen patients for their AWV and during the visit, the patient will bring up an acute problem (ex. ankle pain, cough, etc). If time allows in their schedules, our providers will do a workup of the acute problem and the bill a low level E/M with modifier 25. We rarely have issues getting reimbursement from Medicare in these types of situations. As already said, just be sure the documentation clearly states the reason for the added E/M.


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## Pathos (May 23, 2019)

Check your payers policies on billing AWV and E/M on the same date. Even if the carrier allows it, you probably won't get paid 100% for the second procedure code. Also, keep in mind when the patient comes in for a preventive covered visit, and then ends up with a bill for what the patient might have thought is free, he/she will probably be upset. In this emergency case, the patient might be ok with an extra low level E/M bill, however in general the practice/provider should probably inform the patient about any upcoming bill since the visit was originally intended to be covered by the preventive benefit.

At a previous job, we had a provider who loved to bill 99215 on visits that were meant to be AWVs. Needless to say, the practice received many complaints about this billing practice.


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