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eddletonm

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Our office is currently trying to figure out what to do about coding G0439, 99397, and a 99213 to Medicare advantage plans. I was not aware that the advantage plans started accepting the 99397. My supervisor and I assumed that since Medicare will not pay for 99397 that the advantage plans would not either.
A rep came into the office and let the doctors know that they could and provided us with documentation on this(for the two codes). So if they bill a G0439 and a 99397 should I put a 25 modifier on the 99397?

Also the Doctors are billing all three codes, G0439, 99397, and 99213. Is this allowed? We have done tons of research and have no documentation just reps telling us yes we can. When we ask for documentation stating that we can do this they say "we don't have any".

Please Help we are not getting a straight answer from anyone. :(
 
I work at an ASC and to my knowledge, advantage plans utilize the Medicare contract. So, in my experience, anything that Medicare will not allow, neither will an advantage plan. I have reps come in all the time telling me how to code and bill...they never know what they are truly talking about because they don't know your contracts like you do.
 
Yes, most MA plans will allow both the G0402/438/439 and age appropriate wellness exam at the same visit as long as the documentation meets the requirements for each. We are getting reimbursed for both. We don't charge a 9921x in addition. Most MA plans offer benefits above those of Medicare.
 
You cannot bill G0439 with 99397. See https://www.aapc.com/memberarea/forums/88947-g0439-99397-a.html

You can bill for an office visit if the patient has a problem or complaint, however the documentation needs to clearly separate the components of the problem visit from the components of the wellness exam. And the problem being addressed has to fall outside what would normally be included in the wellness exam.

I will say one thing about this though; there is no charge to the patient for a wellness visit, however when you add a problem visit charge (99213), the patient will then be subject to OOP expenses. Billing a well visit and a problem visit together is generally frowned upon because of this. Patients don't particularly like getting a bill for a visit they thought was going to be at no charge to them. It should definitely not be a routine practice as it will likely raise red flags.
 
hdc said:
Yes, most MA plans will allow both the G0402/438/439 and age appropriate wellness exam at the same visit as long as the documentation meets the requirements for each. We are getting reimbursed for both. We don't charge a 9921x in addition. Most MA plans offer benefits above those of Medicare.
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Thanks! Have yall ever billed all three?
 
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