Internal Medicine Coding Alert

Question: I am new to internal medicine coding. Our clinician recently performed an annual wellness visit for a patient. The patient was seen in the previous year by another doctor who has now left our practice. Since our clinician is seeing the patient for the first time, should I report the patient’s service with G0438 or should I report G0439? Also, if any other E/M services were provided to the patient, can this be reported separately?

New Jersey Subscriber

Answer: You will have to report the services of your physician with G0439 (Annual wellness visit, includes a personalized prevention plan of service [PPS], subsequent visit). You cannot report an initial visit code (G0438, ...initial visit) even though the patient was seeing your clinician for the first time.

This is because CMS specifies that when a patient comes for his/her annual wellness visit (AWV) beyond the third year (the first year, you will be reporting G0402, Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment and G0438 for the second year), you will only be allowed to report the subsequent visit code, G0439 irrespective of who performs the service.

Medicare will pay a physician for an AWV service and a medically necessary service, e.g. a mid-level established office visit, Current Procedural Terminology (CPT®) code 99213, furnished during a single beneficiary encounter. It is important that the elements of the AWV not be replicated in the medically necessary service. You must append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the medically necessary E/M service, e.g. 99213-15, to be paid for both services.