Wiki G0438 denials

[june616]

Hello all! We've had a couple of denials from Medicare for G0438. Reason code PR-149 "Lifetime benefit maximum has been reached. Patient responsibility."

In both cases, this was patient's first G0438 billed from our office. Does this warrant an appeal/refiling on our part? I just to be sure we do everything on our end before we release the balance to the patient. Thank you for your insight.

 

[pjwalsh72]

Since Medicare will only pay for this service once per year, it sounds like another provider has already billed for this service.

 

[OCD_coder]

Before I pass the cost on to the patient, I would try and find out from the patient when their initial was performed first, to try and determine if the subsequent AWV (G0439) can be sent as a corrected claim first.

 

[jryter]

Chances are the initial annual wellness (G0438) was already billed by another provider. In this case, since the initial annual wellness and the subsequent annual wellness visits have the same components, you should be able to refile the charge with the G0439 with no issues.

We have run into the same problem, and after many calls to Medicare, these initial wellness visits were always billed by another provider. We have been able to refile with the correct G-code and have been paid with no problems.