Primary Care Coding Alert

Also, gain insight on using modifier 52.

As primary care coders, you see patient records from all demographics, and keeping all the rules straight can be a challenge. And that’s why “Medicare Wellness Visits” can be confusing to coders.

If you find yourself frequently questioning your own judgment when it comes to coding for the various visits under the mantle of MWVs, this FAQ is for you.

Question: Aren’t Preventive and “Medicare Wellness Visits” the Same Thing?

Answer: No, they’re different. “There’s a huge misconception that they are both the same thing, but they have different purposes,” said Kaitlyn Brack, CPC, CEMC, CFPC, CPEDC, AAPC Approved Instructor, Medicare Quality Coding Analyst at AAPC during her presentation titled The Ins and Outs of Medicare Wellness at HEALTHCON 2023 in Nashville, Tennessee.

Critical: But it’s important to remember that the title “Medicare Wellness Visit” (MWV) is a colloquial term that encompasses three different visits, according to the Centers for Medicare & Medicaid Services (CMS). Though MWV might be used to refer to a specific exam in a clinical setting and by coders, Medicare doesn’t see it that way — and that’s where confusion sets in. CMS lists its “Welcome to Medicare Visit” also knows as the Initial Preventive Physical Exam (IPPE), the Annual Wellness Visit (AWV) both initial and subsequent, and physical exams under the umbrella of MWVs, the agency notes in the MLN release “Medicare Wellness Visits” (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/ medicare-wellness-visits.html).

Additionally, IPPEs and AWVs — due to the typical Medicare billing nuances associated with them — are perennial audit favorites and sit atop Recover Audit Contractors’ (RACs), Targeted Probe and Educate (TPE) reviewers’, and Comprehensive Error Rate Testing (CERT) auditors’ to-do lists.

Essentially, the preventive visit is an age and gender appropriate history and hands-on physical exam with counseling/anticipatory guidance/risk factor reduction interventions and the ordering of laboratory/diagnostic procedures as needed. “It is the physical exam that tends to distinguish a preventive visit from an MWV,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. A physical exam is part of MWV, also, but it tends to be much more limited than that done as part of a preventive evaluation and management service, only including things like height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure. “Medicare wellness is aimed more toward evaluating the patients and how they live. This includes their social surroundings, whether they can take care of themselves, those types of things,” Brack said.

Here’s a quick breakdown of what each entails.

Preventive: This is a history and exam performed with a focus on a patient’s overall health without relationship to treatment or diagnoses for a specific illness, symptom, complaint, or injury. This is a service that’s routinely covered by commercial, Medicaid, and Medicare advantage plans. Traditional Medicare does not cover routine preventive physical exams. These are annual visits based on the date of the patient’s last visit. Coding is structured according to patient age and whether they’re new or established.

For preventive exams, you’ll choose from the following code sets:

• 99381-99387 (Initial comprehensive preventive medicine evaluation and management of an individual… new patient; infant (age younger than 1 year)/ early childhood (age 1 through 4 years)/late childhood (age 5 through 11 years)/ adolescent (age 12 through 17 years)/18-39 years/40-64 years/65 years and older)
• 99391-99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual… established patient; infant (age younger than 1 year)/early childhood (age 1 through 4 years/late childhood (age 5 through 11 years)/ adolescent (age 12 through 17 years)/18-39 years/40-64 years/65 years and older)

Medicare Wellness Visits: These visits are designed to prevent disease and disability for future medical issues based on the beneficiary’s health and risk factors that are measured with a variety of tools. These are covered service by all Medicare payers.

For MWV options, you’ll choose from the following code sets:

• G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment)
• G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit)
• G0439 (Annual wellness visit… subsequent visit)
• G0468 (Federally qualified health center (FQHC) visit, ippe or awv; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV)…)

Note that because G0402, which is also known as the “Welcome to Medicare” visit is limited to a beneficiary’s first 12 months of Medicare enrollment, Medicare beneficiaries are limited to one in their lifetime.