Gastroenterology Coding Alert

Question: Thanks for your article on annual wellness visits last month. We are finding that we perform more and more of these, and we aren’t too sure about the rules. We had a follow-up question: A patient came in for their AWV and while they were being seen, they told the doctor about throat pain after eating spicy food that radiated to their stomach. The doctor performed an exam and scheduled an upper GI for the following week. So can we still bill the AWV as well as that E/M code?

New Jersey Subscriber

Answer: Yes, you can, but you’ll need a modifier and the documentation must include several specific elements. To keep the two codes separate, the doctor should write two different notes — one for the AWV and one for the E/M code. The information being used for the E/M code shouldn’t be used in the AWV note. When documenting, it should be treated as if the patient was seen for two separate encounters.

You should report the AWV code (G0438-G0439) along with the appropriate E/M code (99201-99215). Attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code.

In the CMS document The ABCs of the AWV, the agency says, “When you provide a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service in addition to the AWV, Medicare may pay for the additional service. Report the CPT^® code with modifier 25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury or to improve the functioning of a malformed body member.”

Don’t forget to bill patients for their portion of the E/M service (copayments, deductibles, etc.) even though they typically won’t owe anything for the AWV. Cost sharing will apply to the E/M service that is furnished during the AWV, as the Affordable Care Act only waives the cost sharing requirement for the AWV and not the E/M service.

Informing patients of this obligation is important, since they often understand the “annual physical” won’t have a copayment. It’s often easiest to explain the AWV is entirely for preventative purposes, but a service for any symptom or specific disease follow up is the same as a “usual” office visit.