Internal Medicine Coding Alert

Question: Can we bill an E/M code with a 25 modifier along with annual check-up codes G0438 and G0439?

Florida Subscriber

Answer: Yes, but only if you have thorough documentation that the physician addressed a separate, significant problem that was not preventive in nature.

When the annual wellness visit (AWV) codes were added, CMS noted in the Federal Register that they do not expect to see very many problem services billed on the same date of service as the AWV because of the time involved with performing the AWV. So be sure the E/M problem you’re reporting in addition to the AWV is significant, not minor. For example, during his annual wellness visit, a patient mentions that he has begun experiencing chest pain upon exertion. This statement leads the internal medicine physician to ask questions about the history of present illness, perform a review of systems, and do a relevant exam leading medical decision making and a plan for addressing the chest pain. All of that work is consistent with a problem-oriented E/M service and well beyond what is expected with an AWV. Appending 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) denotes the E/M care was separate from the AWV.

Refresher: You have two codes related to annual wellness visits to choose from for your Medicare patients.

• G0438 — Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit
• G0439 — … subsequent visit.

You’ll only report G0438 once for each patient – the first time she sees one of your physicians for the service. Each year thereafter, you’ll report G0439.