Wiki Annual Wellness Visits

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OGGPPL

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The hospital I work in have few outpatient clinics. OBGYN has been coding & billing Annual wellness visits by CPT codes 99385-99395 & for Medicare Patients G codes.
Hospital also has a Primary Care Clinic same group as GYN and the doctor just hired in Primary care clinic would also like to start with Wellness visits as well. Can I code her patients with regular office visit codes 99212-99215 with ICD 10 Z00.00 as the GYN is already billing the 99385 wellness visit codes and the Primary care might get denied as duplicate.
please advise how should I code the annual wellness visits performed in Primary care considering that the GYN uses the 99385-99395 & the G codes already ?
 
Hi OGGPPL
Yes can bill with Eva Mgnt 99212 to 99214 for regular visit but not use dx Z00 or Z01.4 Again a return visit there must be a problem or need. If pt arriving seeking treatment for a medical problem other than annual pap .What is the dx given for pt seeking care....STD dx Z11.3 , painful periods N94, PID dx N73, UTT infections N39, Fertility problems see dx N97, Endometriosis problems see dx block N80-N80.C or breast problems dx N61. Just using Z dx code all the time may result in denials, the payer wants more info.
I hope helped you with this dilemma
Lady T
 
I am interpreting your question as asking if 2 physicians of different specialties in the same group can both code preventive 99384-99396. The answer is yes, each clinician that is performing a preventive visit should code a preventive visit. In my experience, MOST insurance companies (of course excluding MCR) will cover both an annual wellness by PCP as well as a well woman exam by OBGYN. Each provider uses the appropriate Z code (like Z00.00 for PCP and Z01.41__ for OBGYN). As long as the plan covers both, the claims should process & pay without denials or intervention. Occasionally you may need to write a letter explaining the prior preventive was for the other specialty/dx. If the plan doesn't cover preventive visits or doesn't cover both types of preventive, no amount of appeal letters will get the claim paid. Benefits verification prior to appointment is key so patient may be properly informed about coverage and the related expense.
Obviously if the visit is not preventive and patient is there to address a problem, then 99202-99215 are the more appropriate codes.
 
And the G code " welcome to Medicare visit " and G0438 , G0439. Our GYN is billing these codes that is preventing the Primary care doctor to bill those that is from an Internal Medicine same group. I do understand these G0438 & G0439 are once a year and would prefer the primary care doctor to perform rather than out GYN. What other codes I could suggest GYN to bill instead of G0438 & G0439 ? Please advice.
 
Remember that the instructional notes in CPT indicate that we must report the code that most closely represents the service provided. And HCPCS has the same expectation. All CPT and HCPCS codes have descriptions and documentation guidelines specific to what's expected to be performed if you are going to submit the claims (particularly to government payers). It would not be appropriate to report an E&M service if a preventive service is performed, regardless of the diagnosis code used. Most insurance companies (except Medicare) allow only one preventive visit per year, but sometimes will allow two if one is done by a gynecologist and another by family practice (or other Primary care). Unfortunately, it varies.

For well-person visits, use 99381-99397. IPPE (Welcome to Medicare) and Annual Wellness visits both have coverage and documentation expectations set forth by CMS. And they are billed only once for IPPE and annually for AWV, regardless of the specialty. Additionally, in order to bill them, you must meet the documentation criteria. You can submit Q0091 and G0101 for Pap, Pelvic, Breast exams (some commercial payers will pay), but make sure all of the documentation supports both codes.
E&M visits would be reported only if the patient presents with a complaint. They are not to be used for preventive care. Submitting codes that don't report specifically what was performed can land you into difficulty under the False Claims Act.
Generally speaking, the patient may have to decide who will do her preventive care, as she may have only one opportunity per year for this.
 
Pam Warren said:
Remember that the instructional notes in CPT indicate that we must report the code that most closely represents the service provided. And HCPCS has the same expectation. All CPT and HCPCS codes have descriptions and documentation guidelines specific to what's expected to be performed if you are going to submit the claims (particularly to government payers). It would not be appropriate to report an E&M service if a preventive service is performed, regardless of the diagnosis code used. Most insurance companies (except Medicare) allow only one preventive visit per year, but sometimes will allow two if one is done by a gynecologist and another by family practice (or other Primary care). Unfortunately, it varies.

For well-person visits, use 99381-99397. IPPE (Welcome to Medicare) and Annual Wellness visits both have coverage and documentation expectations set forth by CMS. And they are billed only once for IPPE and annually for AWV, regardless of the specialty. Additionally, in order to bill them, you must meet the documentation criteria. You can submit Q0091 and G0101 for Pap, Pelvic, Breast exams (some commercial payers will pay), but make sure all of the documentation supports both codes.
E&M visits would be reported only if the patient presents with a complaint. They are not to be used for preventive care. Submitting codes that don't report specifically what was performed can land you into difficulty under the False Claims Act.
Generally speaking, the patient may have to decide who will do her preventive care, as she may have only one opportunity per year for this.
Click to expand...
Thank you. I had the same thoughts of letting patient decide as to who she wants to have this preventive care provide. As both GYN and Family Med can meet documentation guidelines to bill these codes, I just was not able to suggest who should be performing this. Thank you Pam. I like the resolution of having patient pick as it is once a year. I truly appreciate your quick response and feedback here. Thank you.
 
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