Primary Care Coding Alert

Question: One of our providers completed her first annual wellness visit for a patient. Most of the patients think this is a physical, but we know it is different. This is the first wellness check for the patient. Do I bill 9921x and G0438, or do we submit one code or the other, but not both?

Mississippi Subscriber

Answer: Assuming that the wellness visit is the only service rendered, you should report only the wellness code, G0438 (Annual wellness visit; includes a personalized prevention plan of service [PPS], initial visit).

E/M explanation: You should only include an E/M code if your provider needs to treat the patient for a specific diagnosis during the visit and performs and documents the work associated with a problem-oriented E/M service. For example, the patient schedules a wellness exam and presents with an illness, which the provider treats during the course of the encounter, in addition to providing the annual wellness visit. In this situation, you could report the appropriate E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and the supporting diagnosis, plus the wellness visit code.