Wiki New medicare patient vs welcome to medicare.

[hlv89]

SOMEONE HELP ME!!!!

I CURRENTLY WORK FOR A FAMILY PHYSICIAN AND WE CAME ACRROS WITH A NEW PATIENT WHO HAS MEDICARE. I BILL MEDICARE USING G0438 THINKING THAT CODE IS USING FOR NEW PATIENT. NOW I AM GETTING A DENIAL CODE N117 : THIS SERVICE IS PAID ONLY ONCE IN A PATIENTS LIFETIME. SO WHICH CODE SHOULD I USED.. THE G0439 FOR AN ESTABLISH PATIENT? THE PATIENT IS CLEARLY NOT NEW TO MEDICARE, BUT SHE IS NEW TO THE PRACTICE WHERE I WORK.. SOO CONFUSED.

 

[OCD_coder]

Your are confusing established and new patient based on CPT. The IPPE is only paid once in a patients lifetime as is the Initial ANW (G0438). IPPE- first 12 months. G0438-after the first 12 months.

The ANW are based on when they occured/reported to Medicare. So it seems that the patient all ready had a G0438 billed.

G0438, is performed on patients that have been enrolled with Medicare for more than one year. Think of this as their initial visit by Medicare standards. Don't confuse this as new patients to the provider.

A patient is eligible for their subsequent AWV, G0439, one year after their initial visit, 366 days apart.

IPPE Visits occur in the first 12 months a patient is enrolled in Medicare:
Remember that during the first year a patient has enrolled with Medicare the patient is eligible for the Welcome to Medicare visit or IPPE, Initial Preventative Physical Exam. This exam is billed using HCPCS code G0402. An Annual Wellness Visit code of G0438 should not be used and will be denied since the patient is eligible for the Welcome to Medicare visit during the first year of enrollment.