Wiki Medicare Annual Wellness Visit with Sick Visit

[urbach34@yahoo.com]

I have a PCP that I code for who constantly bills Medicare Annual Wellness Visit (G0439) with Sick Visit (99123). I understand that you are able to bill both services at the same time if you use -25 modifier on the 99213. My problem is, I am starting to question the legitimacy of how often he is billing this. Every single AWV has a 99213 with it! I am under the understanding that to appropriately bill these two services, 1. the patient has to be coming in for the AWV and 2. something is discovered or brought up during the Wellness that requires above and beyond the Wellness, hence the addition of the 99213. I am seeing the office note say the patient is coming in for congestion and doctor is billing AWV with 99213 for congestion. It looks as though the patient is coming in for a sick complaint and doctor is seeing that is has been over a year since their last AWV and adds it on to the 99213. Someone please clarify! I have brought this to the attention of the office manger as well as my boss at the billing office and they act as though I don't kow what I am talking about. As the certified coder, I am concerned that I will be the one on the line if this is in fact fradulent!

 

[mitchellde]

ICD-10 CM has an excludes 1 note for the Z00.0 codes for encounter for signs and symptoms. You must defer the wellness if the patient expresses complaints/concerns. If the provider discovers an abnormal finding then you may code the Z00.01 with the finding as the secondary. Then you may code an ov for the abnormal finding

 

[urbach34@yahoo.com]

So, if the patient is the one to call in and say they have congestion, then the doctor is to bill only the sick visit with the appropriate dx code. But on the other hand, if they come in for AWV and doctor hears congestion in the lungs and proceeds to bill an office visit for further evaluation then I am allowed to bill both services.

Example:

G0439 with Z00.01 & R09.89
99213-25 with only R09.89