Primary Care Coding Alert

Tip: Appending modifier 25 can help save AWV with some claims.

Until now, you've been able to report some components of annual wellness visits (AWVs) separately from the AWV. That will no longer be the case effective July 1, thanks to the latest round of Correct Coding Initiative (CCI) edits.

CCI version 17.2, which takes effect July 1, offers 2,367 new edit pairs and deletes 336 bundles, according to an analysis by Frank Cohen, MPA, MBB, principal and senior analyst with The Frank Cohen Group, LLC. The majority of edits impact the codes from the musculoskeletal code range (20000-29999), but bundles did occur to codes throughout the CPT® manual.

Avoid AWV With Health/Behavior Assessment

Most edits of interest to family physicians center on AWV codes G0438 (Annual wellness visit; includes a personalized prevention plan of service [PPS], initial visit) and G0439 (Annual wellness visit; includes a personalized prevention plan of service [PPS], subsequent visit).

Explanation: Because the AWV is a preventive wellness visit, many of its components overlap with the health and behavior assessment/intervention codes (96150-96154) and medical nutrition therapy (MNT) codes (97802-97804). The new CCI edits clarify that CMS will no longer allow you to report any of these codes with an AWV. If you do report the services together, you'll collect for the AWV but not for the assessment or MNT. The edits don't allow you to separate these pairings under any circumstances.

AWV With E/M Could Be Legit -- With Modifiers

The status of AWVs with E/M visits brings better news. CCI 17.2 bundles office visit codes 99201-99215 into both G0438 and G0439, but don't lose hope. You can append a modifier (such as 25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code if you have a medically necessary reason to separate these bundles, and be paid for both services.

Remember: CMS already requested that you append modifier 25 when reporting an E/M code with an AWV. CMS Transmittal 2159, issued on Feb. 15, noted, "When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT® codes 99201-99215 may be reported depending on the clinical appropriateness of the circumstances. CPT® Modifier 25 shall be appended to the medically necessary E/M service . . . ."

CMS went on to remind practices not to double dip for any AWV and E/M services, stating, "Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable, E/M service."

Note: The language from CMS Transmittal 2159 above has been incorporated into Section 30.6.1.1(h) of Chapter 12 of the Medicare Claims Processing Manual. The new edition of CCI simply makes the previous statements official by including the change in edits.

ECG bundle: You'll also find ECG codes 93000-93010 (Electrocardiogram, routine ECG with at least 12 leads ...) bundled into AWVs. The edits carry a modifier indicator of 1, meaning you can use a modifier to separate these bundles when both services were medically necessary and performed as distinct procedures.