Medicare Compliance & Reimbursement

Part B practices looking for answers about the new annual wellness visit (AWV) services that Medicare allows this year have come up short, with CMS still waiting to release more comprehensive coding guidance on the matter than the MLN Matters article that the agency issued months ago. But MACs have continued to share answers to the frequently-asked questions that they've received on the topic, and we've got a few of the answers to help you ensure that your G0438-G0439 claims process smoothly.

Question 1: Can we collect for an AWV that we perform on a patient we've never treated before?

Answer: Absolutely. "There is no regulation the patient has to be established," WPS Medicare notes on its Web site. The MAC, which is a Part B payer in four states, indicates that if the patient had an AWV at another practice during a prior year, you'll report G0439 (Annual Wellness Visit, includes a personalized prevention plan of service [PPPS] subsequent visit) for your service. If the patient has never had an AWV before, you'll bill G0438 (...first visit).

Question 2: What type of documentation does Medicare require for recording the AWV?

Answer: You'll want to document the AWV the same way you document all other services that your practice performs thoroughly and carefully.

According to a directive on the Web site of Trailblazer Health Enterprises, a Part B payer in five states, "Physicians, qualified non-physician practitioners, and medical professionals are required to use the 1995 or 1997 E/M documentation guidelines to document the medical records with the appropriate clinical information. All referrals and a written medical plan must be included in the documentation."

Question 3: Is G0438 a "once in a lifetime" code?

Answer: Yes, you can only report G0438 once per beneficiary. If you submit a claim for G0438 and Medicare has already covered that beneficiary for another instance of that code, you'll receive an EOB with claim adjustment reason code 149 (Lifetime benefit maximum has been reached for the service/benefit category), according to Pinnacle Business Solutions, a Part B MAC in two states.