Practice Management Alert

Question: We have several AWV charges (G0438) that have been denied because we attached a modifier 25 because an injection was given during that same visit. Normally we attach the modifier 25 to office visit. Are we billing this incorrectly?

Maryland Subscriber

Answer: Medicare will deny the annual wellness visit (AWV) you're billing with G0438 (Annual wellness visit; includes a personalized prevention plan of service [PPS], first visit) if you attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). There reason is that G0438 and other G codes are not problem-oriented E/M services to which that modifier applies as defined under the modifier 25 usage rules.

You should just bill the injection separately.

Remember: The purpose of the AWV is to provide a preventive planning service, not take care of problems the patient has at the same time. "The Federal Register made this very clear in the final rule -- they expect problems to be addressed at a different visit, but when there is a rare circumstance that warrants dealing with a problem at the time of the AWV," warns Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. "They will allow a problem E/M service to be billed and that code requires the modifier 25. Injections would be coded separately, but then Medicare may decide to deny the injection procedure at the time of the AWV because they have decided to bundle it -- not bundled now, but who knows what they will do next quarter."