# Coders: Annual Wellness Visit--Read the Guidelines!!



## Pam Brooks

I have seen many threads on this topic that worry me...

Coders, I urge you to make sure you carefully read the MLN Matters MM7079 and the related CR Transmittal R134BP and R2109CP.

I see a lot of you using the words "Annual Physical", or "Preventive Physical".  The Annual Wellness Visit is not a head-to-toe physical exam.  This is a risk assesment to help physicians put together a patient-specific plan for preventive care.  Physicians need to know exactly what criteria are expected for this high-RVU visit.  It's up to us, as certified coders to make sure our physicans have the tools and information they need so that they can complete this visit with the appropriate documentation.  Believe me, Medicare is going to be auditing this.  

The press has erroneously reported that Medicare is now paying for preventive physicals or preventive exams, and our Medicare population is going to be calling your offices, asking for their 'free physical'.  Based on the criteria for this covered service, the only objective portion of this encounter is the gathering of vitals. Let's not compound the problem by using the wrong language when describing these services.  It will be up to us to educate the patients and our providers that this is not a physical exam, as would be reported by codes in the 99381-99397 range.


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## Cpeterson2010

*Annual Wellness Visits*

Thanks for your information Pam.  

What is your opinion to using this new code "G0438 and the G0439 along with the        G0101 on the same days visit; and could you use a modifier??    Will the providers have to do these on separate visits to be sure they are reimbursed correctly?   
Also, any type of sick visit I would guess we could use the modifier 25 on say a 99213 on the same day as a G0438 or G0439 if this should happen to take place on the same day?

Any coder's input would be appreciated!  Thanks CP


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## LindaEV

Cpeterson2010 said:


> Thanks for your information Pam.
> 
> What is your opinion to using this new code "G0438 and the G0439 along with the        G0101 on the same days visit; and could you use a modifier??    Will the providers have to do these on separate visits to be sure they are reimbursed correctly?
> Also, any type of sick visit I would guess we could use the modifier 25 on say a 99213 on the same day as a G0438 or G0439 if this should happen to take place on the same day?
> 
> Any coder's input would be appreciated!  Thanks CP



You can use the G codes on the same day (no modifier needed). Also applies to a sick visit...and yes you would add a -25 on that one.


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## Lisa Bledsoe

Pam Brooks said:


> I have seen many threads on this topic that worry me...
> 
> Coders, I urge you to make sure you carefully read the MLN Matters MM7079 and the related CR Transmittal R134BP and R2109CP.
> 
> I see a lot of you using the words "Annual Physical", or "Preventive Physical".  The Annual Wellness Visit is not a head-to-toe physical exam.  This is a risk assesment to help physicians put together a patient-specific plan for preventive care.  Physicians need to know exactly what criteria are expected for this high-RVU visit.  It's up to us, as certified coders to make sure our physicans have the tools and information they need so that they can complete this visit with the appropriate documentation.  Believe me, Medicare is going to be auditing this.
> 
> The press has erroneously reported that Medicare is now paying for preventive physicals or preventive exams, and our Medicare population is going to be calling your offices, asking for their 'free physical'.  Based on the criteria for this covered service, the only objective portion of this encounter is the gathering of vitals. Let's not compound the problem by using the wrong language when describing these services.  It will be up to us to educate the patients and our providers that this is not a physical exam, as would be reported by codes in the 99381-99397 range.



You are absolutely correct Pam!  These new "services" are not physicals in any way shape or form.  The only "hands on" required are vitals.


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## Pam Brooks

Cpeterson2010 said:


> Thanks for your information Pam.
> 
> What is your opinion to using this new code "G0438 and the G0439 along with the        G0101 on the same days visit; and could you use a modifier??    Will the providers have to do these on separate visits to be sure they are reimbursed correctly?
> Also, any type of sick visit I would guess we could use the modifier 25 on say a 99213 on the same day as a G0438 or G0439 if this should happen to take place on the same day?
> 
> Any coder's input would be appreciated!  Thanks CP



Our contractor NHIC hasn't yet come out with the guidelines for those scenarios....in fact, we're still waiting for our 2011 preventive care criteria!   

Because the G0101, G0102 and Q0091 are 'separately identifiable' from the G0438 and 
G0439, I anticipate that we will be able to bill them as long as we appent the -25 on the 
G0438/9.

What I do know about billing the E&M at the same time (i.e 99213) is that the documentation criteria for the AWV includes a great deal of PFSH, and we would not be able to double-dip to use that information to also support an E&M.  Basically, anything covered in the AWV could not be considered in a separate E&M...which might limit our higher-level E&M visits.  We couldn't count vitals as part of our E&M exam, for example.
Although CMS might not come out with crystal-clear guidlelines regarding these new codes,  we can pay attention to the guidelines that are currently in place and use them accordingly for this circumstance.  

Pam


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## dawnsilva

*annual wellness visit*

according to the Medicare Claims Processing Manual Chapter 12, section 30.6.1.1 under 2. Annual Wellness Visit, it states "allows for a preventive physical exam, called the annual wellness visit".


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## Pam Brooks

Yes, and there lies the problem....even CMS is contradicting themselves.


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## dawnsilva

Not quite sure how is it a contradiction if this is what CMS is stating the wellness visit is?


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## brake

*annaual Wellness forms or checklist*

I'm trying to educate my providers and staff; are there any forms or checklist to prompt questions to the patients from the providers so the documentation will be correctly indentified by the criteria? Thanks


Chiquita S. Brake,CPC


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## pglazener

I just want to clarify to make sure I understand the new codes.  

If a patient has had their IPPE and is an established patient with a doctor, we would use G0439 for their subsequent AWV as long as it's 12 months after the IPPE.

If a patient has had their IPPE with another doctor and comes to our practice at least 12 months after the date of their IPPE, we would use code G0438.

Is this correct?


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## Pam Brooks

dawnsilva said:


> Not quite sure how is it a contradiction if this is what CMS is stating the wellness visit is?



Well, your previous post pointed it out.  "preventive physical exam"  which is an Annual Wellness Visit.

In reading the criteria for the AWV, there's precious little exam component. 

I didn't intend to incite an argument, just suggested that everyone use the language that will be most clear to our patients and providers.


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## Pam Brooks

brake said:


> I'm trying to educate my providers and staff; are there any forms or checklist to prompt questions to the patients from the providers so the documentation will be correctly indentified by the criteria? Thanks
> 
> 
> Chiquita S. Brake,CPC



I can send you the FAQs I prepared for my providers and our patients.  I also have a checklist for the guidelines. 


Send me a PM, with your email, and I'll be happy to get that to you.  

Pam


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## margie513

Good Afternoon Ms. Brooks
Is there any way that you could share your FAQs for the provider and patient as well as your checklist for the guidelines. I'm trying to provide my physicians with a better clarification on this new Annual Wellness Visit. I would really appreciate it.

Margie Delgado
mdelgado@norwalkmedgroup.com

Thank you in advance


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## vickibrown

LindaEV said:


> You can use the G codes on the same day (no modifier needed). Also applies to a sick visit...and yes you would add a -25 on that one.


I have just received my first EOB from Medicare for 2011 whick I billed E/M visit with the AWV.  Medicare has paid the OV and denied the AWV due to non covered services because this is a routine exam done in conjuction with a routine exam.  Modifier 25 was added to OV code.  Would we also add another modifier to the AWV?  Desperate help needed, we have done 175 of these exams.


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## mitchellde

what was the reason for the ov?


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## perkins05

*Awv*

Hi Pam could you please send me a copy of your  FAQ and checklist:



Thanks
gwenmperkins@yahoo.com


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## cheermom68

*Awv*

In a teleconference from NGS yesterday, we were told to hold these claims until 4/4/2011 because that is the implementation date.  They said that if you bill them now they should be paid but would not be tracked properly until 4/4.  They also stated that if you use V70.0 for dx it would be denied.  They could not give an appropriate dx however.  They said that they were going to try to get there systems to accept the V70.0 when billed with these codes and would let us know if and when they did.  They highly advised holding these claims until 4/4.

LeeAnn


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## MMAYCOCK

No, G0438 is not dependent on the Welcome to Medicare IPPE visit. That is not an annual benefit. The 
G0438 is used for the First Annual Wellness Visit- Other than the mandatory time lapse, it doesn't matter if the patient did or did not have the IPPE. The G0438 is used the first time the patient takes advantage of the annual wellness visit. Every year after that, the G0438 will be used to indicate that it is a subsequent wellness visit and that the first annual wellness visit has been performed - by your office or another. That is not a factor.


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## MMAYCOCK

No, G0438 is not dependent on the Welcome to Medicare IPPE visit. That is not an annual benefit. The 
G0438 is used for the First Annual Wellness Visit- Other than the mandatory time lapse, it doesn't matter if the patient did or did not have the IPPE. The G0438 is used the first time the patient takes advantage of the annual wellness visit. Every year after that, the G0438 will be used to indicate that it is a subsequent wellness visit and that the first annual wellness visit has been performed - by your office or another. That is not a factor.


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## MMAYCOCK

LeeAnn,

I'm really curious to hear if providers were allowed to respond to NGS" instructions to hold these claims until April? Were they allowed to give feedback?

Melanie


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## cheermom68

*Feedback*

They did not allow questions or feedback, but gave the e-mail for support to send questions.
They pretty much just read the powerpoint that stated the guidelines.
LeeAnn


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## sallywilkins

Lisa Curtis said:


> You are absolutely correct Pam!  These new "services" are not physicals in any way shape or form.  The only "hands on" required are vitals.


Thank you for sharing your knowledge. We so appreciate it! We feel unsure of what to do!


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## joanmkruse

CMS does refer to the AWV as a preventive exam. It's stated twice: 

Annual Wellness Visit (AWV) 

Effective January 1, 2011, Section 4103 of the Affordable Care Act (ACA), allows for a preventive physical examination, called the annual wellness visit (AWV), and includes personal prevention plan services (PPPS). The AWV is a new annual Medicare preventive physical examination, available for eligible beneficiaries, and identified by new HCPCS codes G0438 (Annual wellness visit, including PPPS, first visit) and G0439 (Annual wellness visit, including PPPS, subsequent visit). 


http://www.cms.gov/Transmittals/downloads/R2109CP.pdf


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## mitchellde

I have gone over this with the fine toothed comb so to speak and sat with a physician while we went over the requirements and role played out the visit.  There is no way to accomplish all of the requirments with merely vital signs.  The provider must examine the patient to determine if there is evidence of any cognitive imparement, or to review for functional ability.  While they have specifics that must be documented to meet the objectives, in order to document these things the provider needs to perform certain examinations.  I am not totally comfortable with telling the provider that this is not a preventive examination, that it is vitals only.  I think this is an incorrect message, and also we must remember that the patients were told by Medicare they would pay nothing for preventive services after january 1 2011.  To use the AWV as a vital signs only and then reschedule the patient for the preventive encounter is going to be an issue, if you try to bill this as preventive, Medicare will deny it and the patient will be responsible which will cause great concern with these patients, or to reschedule a preventive and bill it as a level 4 or 5 encounter to have Medicare pay for it is potential for fraud.  I agree with the above.. AWV is a preventive EXAMINATION encounter.


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## joanmkruse

Great post Debra!

Also...on another thread here (under general Medicare discussions I believe), there is a quote from a person at CMS who stated that the AWV is intended to be a continuation of the IPPE, even though the words "physical exam" were not specifically mentioned.

Providers I've talked to agree with your thoughts that it would be difficult to do the AWV without examining the patient.


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## Jewel

*G0438-G0439: Screening diagnostic tests*

What are the specific "screening labs” entitiled under these visits? It has not been clarified what those labs are (Welcome to medicare allowed for EKG and US abdomen if history of AAA).  Has anyone found the reference regarding the above?  Thanks in advance


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## cstrickland

*g0439*

what diagnosis code do you use with the G0438/G0439?


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## Pam Brooks

mitchellde said:


> I have gone over this with the fine toothed comb so to speak and sat with a physician while we went over the requirements and role played out the visit.  There is no way to accomplish all of the requirments with merely vital signs.  The provider must examine the patient to determine if there is evidence of any cognitive imparement, or to review for functional ability.  While they have specifics that must be documented to meet the objectives, in order to document these things the provider needs to perform certain examinations.  I am not totally comfortable with telling the provider that this is not a preventive examination, that it is vitals only.  I think this is an incorrect message, and also we must remember that the patients were told by Medicare they would pay nothing for preventive services after january 1 2011.  To use the AWV as a vital signs only and then reschedule the patient for the preventive encounter is going to be an issue, if you try to bill this as preventive, Medicare will deny it and the patient will be responsible which will cause great concern with these patients, or to reschedule a preventive and bill it as a level 4 or 5 encounter to have Medicare pay for it is potential for fraud.  I agree with the above.. AWV is a preventive EXAMINATION encounter.



Ah, I can always count on you ....!  LOL

I agree, from a physician's perspective, they must examine the patient in order to determine cognitive defects, etc. but in considering the exam bullets in our audit tools, there are few instances where an exam of any detail would take place, for most patients.

Overall, there is currently no requirement to do a head-to-toe exam, but in order to satisfy the psychiatric and functional elements of the AWV, the provider may have to do some of the examination elements, based on the patient's risk assesment.  The only straightforward hands-on exam requirements (from an auditing perspective) specifically for the AWV are the vitals.  For those providers using an EMR (such as mine), we have built specific templates to satisfy all of the AWV critiera; and in order to be able to provide this service in a timely manner, we excluded our standard Pe template, with the exception of the vitals. Of course, in order to meet the criteria as required, an examination in some form would take place, which we do allow them to document,  but we did this within the confines of our customized template, and not as part of our standard Preventive physical. Thinking outside the box, as I have to do in the EMR world, we had to exclude our standard Pe template in order to have time and space to capture all of the required data.  

This is what I wanted to convey...that from a workflow perspective, it could get cumbersome to also document a head-to-toe, if it's not medically necessary.   My doctors (Just our 45 primary care providers)  fully understand the requirements of the AWV, and would not assume that they shouldn't 'examine' the patient in order to assess their risk.

We also have to be very careful that we are not giving the wrong message to our patients, by giving them a blanket statement that preventive examinations are covered. In their minds, they might expect a hands-on, head-to-toe exam, and then will be annoyed if that's not what we provide.  We did create a patient FAQ specifically to address this, but CMS has a very nice informative brochure that you certainly could all provide to your practices.  

For those of you that continue to have questions, you really should contact your local contractors.  Some contractors seem to be handling this differently, and I can only speak to what I've learned from NHIC.  There is much information on the CMS website, which we should all have in our "Favorites", and we have to make the best decisions for our providers regardless of what other coders (including myself) have done for their practices.


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## ktplem

May I also have a copy of your FAQ's?

kate.plemel-dibble@vtmednet.org


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## rthames052006

Jewel said:


> What are the specific "screening labs” entitiled under these visits? It has not been clarified what those labs are (Welcome to medicare allowed for EKG and US abdomen if history of AAA).  Has anyone found the reference regarding the above?  Thanks in advance



CMS has a quick reference on Medicare Preventive Services on their website...

http://www.cms.gov/MLNProducts/downloads/MPSQuickReferenceChart1.pdf


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## mrs.price0915@gmail.com

MMAYCOCK said:


> No, G0438 is not dependent on the Welcome to Medicare IPPE visit. That is not an annual benefit. The
> G0438 is used for the First Annual Wellness Visit- Other than the mandatory time lapse, it doesn't matter if the patient did or did not have the IPPE. The G0438 is used the first time the patient takes advantage of the annual wellness visit. Every year after that, the G0438 will be used to indicate that it is a subsequent wellness visit and that the first annual wellness visit has been performed - by your office or another. That is not a factor.



The subsequent visits should be billed with the procedure code G0439.


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## deut649

*AWV questions*

my docs have questions about this, which i have been unable to get from the website and I have left messages for Medicare to call me back.  when they say one AWV a year is it 365 days (exactly) or if they have a AWV in January can they have a subsequent on the next January? My doc wants this in writing from them....Where can I find this?
On the MLN pertaining to the AWV it states effective January 1 2011, implementation date of April...what does the implementation date stand for.  Any Help is appreciated.


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## MMAYCOCK

*AWV timeframe between visits*

Question: 
The guidelines on the AWV show that Medicare will allow the service once per year. Is this period based on a 365-day year or 12 months? 
Answer: 
Medicare would look to verify that at least 11 full months have passed since the last AWV. 


Here is the link to the full Q&A page - this is from WPS

http://www.wpsmedicare.com/j5macpartb/resources/provider_types/awv-faq.shtml


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## Peter Davidyock

Usually "Once a year" is pretty clear. Does your Dr not understand the concept of time?
I mean come on really? Stand up and tell him. One yr equals 365 days Doc. Schedule the pt back on the 366th day. Issue closed.
I would approach a situation like this as follows:
It's your practice Dr., the guidelines for the AWV clearly state one per yr.
I am advising that you do not schedule any more than that.


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## Pam Brooks

Oceanlivin said:


> Usually "Once a year" is pretty clear. Does your Dr not understand the concept of time?
> I mean come on really? Stand up and tell him. One yr equals 365 days Doc. Schedule the pt back on the 366th day. Issue closed.
> I would approach a situation like this as follows:
> It's your practice Dr., the guidelines for the AWV clearly state one per yr.
> I am advising that you do not schedule any more than that.



LOL....I needed a laugh this morning......This is why we'll always be employed!  

I was once told by a physician colleague (who is also a certified coder) that his CPC exam was far more challenging than his medical boards.  

Enough said.  Keep up the good work everyone!


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## henrylg

Hi,

Could you please send me your brochure and check list? My email address is henrylg@umdnj.edu.

Thank you,
Linda


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## susiekay

Decision Health has an encounter form on their website that you can print out and use for the new wellness visit, G0438 & G0439


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## sbates

I was able to locate some very comprehensive paperwork on the AAFP website if your physicians have membership/access which states at the bottom may be photocopied or adapted for use by physicians in their own practices.  If you don't have access try http://www.aafp.org/fpm/20110100/p22.html to possibly get straight to the forms.


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## coppercent

*G0438 and G0101*

I billed these without any modifiers and the G0438 was denied.  Would I use -25 or -59? Is G0438 considered an E&M or procedure?  If a modifier is needed, then why isn't it listed in the NCCI edits??? Thanks


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## sparkyboop

Pam,
Could you share your FAQs you prepared?  

Thank you,
Janet
jclark@adaptivebilling.com


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## ohn0disaster

I would also really appreciate a copy of the FAQs, please?
vmier@mccigroup.com

Thank you!


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## jcdavis2007

*Wellness visit*

Could you send me the info you have and the check list please.

Spunkyduck@cox.com

Thanks


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## annielou

*Awv*

That sounds correct. Our doctors, after I gave them the guidelines, have adhered very well to covering and documenting everything required by the AWV guidelines.  I did have to reiterate that if they bill for an E/M at the same time, they cannot use a combined ROS, vitals, etc for both codes. Generally they are providing the AWV when the patients come in for a thorough annual review of their medical problems, so, after reviewing the notes, i often go back to the docs and have them downcode the E/M so that they aren't counting some of the requirements twice, even though they are only documented once.  We have been doing a lot of these AWVs and I think it is good for the doctor and the patient to have them reflect on their wellness care; what has been done already and what needs to be done in the future. The revenue is good and I believe the intention of Medicare to make sure our patients are keeping up with their wellness needs is a good thing.  We are a family practice, by the way.


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## amy_mousie

*AWV check list*

Could you send me the info you have and the check list please.

wrightam@sjhlex.org

Thanks Amy Wright, CPC CCP CMBS


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## kjiang

*wellness visit thread*

Hi Pam,

Could you please send me a copy of your FAQ and checklist:

kkathy12@hotmail.com

thank you


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## kjiang

*Complete Physical Exam*

Are hearing screening and visual screening part of CPE or separately billable?  Are there written guidelines available?

thank you for your input


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## maschneck

We had Medicare and Wellcare Medicare come to our office and explain the policies on the G codes and office visits. They said, that if the doctor does an E/M visit with the G code, use a 25 mod on the G code and the E/M code. However, you need to be sure to put any V codes with the G code (ie. G0439) and the diagnosis codes on the E/M code.


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## Pam Brooks

Here is the Patient Information FAQs that we use.  It's a combination of information from CMS, and info from our practices.  Use what you need.


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## dkbilling

*Mcr awv*

I am undestanding that there should be something such as the Beck's depression screen used to glean the risks for depression. Shouldn't that document then be part of the medical record for the date of service of the AWV?  Darlene Billing, CPC


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## espressoguy

Pam Brooks said:


> Here is the Patient Information FAQs that we use.  It's a combination of information from CMS, and info from our practices.  Use what you need.



Pam,

Would it be ok to pass this on to my boss for possible use in our clinics?

Thanks,


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## douglaswong

*medicare icd9 for laboratory preventive screening*

need your help!  what icd9 do you all use for routine laboratory screening for Medicare recipients and even when you have no clue as to what the patient may have medically?


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## Pam Brooks

@ Doug--There is a preventive care guide (check CMS) that identifies the tests and approved diagnosis codes allowed for coverage by Medicare.  But Medicare does not cover most routine screenings.  V72.62 is the code for lab work done as part of a routine visit, but this will not be covered by Medicare.  For this population, you are better off to determine whether or not the provider is ordering a surveillance lab to monitor a patient's chronic conditions, than you are to assume it's routine. If you "don't have a clue", I'd advise you to query the physician to get one, or you'll be getting phone calls from angry patients.   

@espressoguy---sure, you can use that however you wish.


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## AB87

I work for a family practice also and they are asking me about billing G0444 (screening depression) along with the AWV. I read the guidelines and screening for depression is already being Done within the AWV. Is anyone billing G0444 Along with the AWV??? Too me it seems like unbundling


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## MnTwins29

Pam Brooks said:


> Here is the Patient Information FAQs that we use.  It's a combination of information from CMS, and info from our practices.  Use what you need.



Thank you Pam.   This Q & A is much simpler to explain to our MDs and Site Sups than some of the straight CMS docs.  I plan on using this in my educational sessions, if you don't mind.


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## Renev

*New to coding!*

Hi Pam,

Could you please share a copy of your FAQ and checklist:
My email address is renujay@sbcglobal.net.
Thank you .


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## Pam Brooks

It's posted within this thread.


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## lawnmedical

I am looking for some assistance in regards to doing a preventative with g0442 and g0444.  If we do a preventative can we still bill for both the the alchol screening and depression screening at the same time.  We have done a 99396 with a 25 modifier and then a G0442 with no modifier and then a g0444 with a 59 modifier on the same claim.  BCBS will pay the 99396 and the g0442 but not the g0444, saying that the modifier that they don't like the modifier that has been used.  We also have done it with no modifier on the g0444 and they are still using the same denial code of not liking the modifier.  Any help that you can give us would be greatly apprecitated.
Chris Milewski
Lawn Medical Center
lawnmedical@comcast.net


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## maddismom

You don't need the modifier 59.  G0442 and G0444 do not have any CCI conflicts.  Not sure why you were using it, but I would get rid of it and you'll probably get paid.


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## e.ladora@yahoo.com

*Thank you!*

I needed to read this! It helped a LOT!!


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## clearblue

*Medicare physicals and initial/subsequent*


So I am very confused on all of these services. We are having our software people (clearly not coders) telling us we cannot bill these G0402, G0438 and G0439 visits unless the patient is 65 or older. When researching on CMS (in Iowa we are now under Noridian) I can't seem to make heads or tails of any of this information. I did print out Pam Brooks PDF she provided. Can someone help straighten this out for me? My question is this- if we have Medicare insured women coming to the clinic for a pap smear and physical, for example, how would you code this. This is just an easy quick example I'm providing to see where I'm missing the boat if I am!

Thanks

Erin, CFPC


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## brgallagher5@verizon.net

*Billing G0438 or G0439 with 93000?*

We have been having a debate in the office regarding billing G0438 or G0439 with a 93000 and what modifier is used. Some people are saying 25 on the G code and others are saying 59 on the 93000. Can you help me?


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## JHCARR

On the CMS website there are booklets that explain these wellness exams
and Preventive exams.  I have printed these to have in case I am asked
about what Medicare covers and how often.
It is confusing for the patients, they think they are physicals which they
are not.  
Hope this is helpful.

Janice Carr, CPC


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## piecesjkh

*Annual Wellness for younger Medicare patients*

I am reviewing a visit for a patient who is in their 30's and on Medicare. The provider billed an AWV. They did not document a written screening schedule for the next 5 to 10 years which is required to bill the service. What I cannot wrap my head around is the patient is not a typical Medicare patient based on age. So how would that work as far as to what would be on their checklist? What screenings would be appropriate?

Any help would be greatly appreciated!
Joyce


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## Kisalyn

Wouldn't you just fill out the year they would be due for the screening service?

For colon cancer screening starting at age 50, you would put the year they turn 50. Anything that doesn't apply, they put "N/A".

Fill it all out and mail a copy to the patient. You can then bill the AWV.


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## mariselaa

*Confused*

1.) Are we allowed to do both the Physical Exam and AWV and bill for both services separately? (Ex: 99397, G0438)

2.) If we have a patient with Private insurance Primary and Medicare Secondary are we able to do both AWV AND Physical exam and bill the physical Exam (99397)  to the private payer and the AWV (G0438)  to Medicare?

All help and thoughts are greatly appreciated!

Thanks, 

Marisela


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## MBass

*Confused-Medicare Annual coding*

If the physician did not document a AWV... instead he documents a head to toe annual exam for Medicare patient, how would you code this? I know when a breast and pelvic is specified but the physician has done more than a breast and pelvic, you can use the carve out method for 99397 G0101 but what if it does not specify breast and pelvic, but just annual exam ? Do I still use the carve out method and count the physical as breast and pelvic since he did indeed examine the breast and pelvic? It is definitely not a AWV. I just want to make sure I am not missing something here. I have been researching and still do not feel positive enough about it. Thank you!


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## cpoeward

He must document all the components of the AWV, if he exceeds the criteria that is okay.  There is no carve-out for AWV.  If he doesn't meet the criteria, you would bill the appropriate CPE.


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