Wiki Preventive Exams with Medicare Advantage Plans

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alester76

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Can anyone please assist me with proper coding for a Preventive Exam for Medicare Advantage/Medicare +Blue plans?

I am being told that a preventive visit is covered, as in 99396 or 99397 but I cannot get claims to scrub with these codes. Just recently I have started getting rejections and / or patients being billed for these visits. Plan states there is a preventive code but they wouldn't give it to me.

Please help!..Thanks so much
 
We bill Medicare and MCR Advantage plans the Annual Wellness Visit codes G0438 and G0439. We never use 99396 or 99397 for Medicare/MCR Advantage, because they are not a covered code.
 
Most advantage plans pay for the annual physical codes in addition to the AWV. There services are not comparable or interchangeable so you cannot bill a full physical under AWV code and vice versa. AWV is a cognitive service, its not a hands on full physical like 99381-99397. It may need a modifier if performed on the same date.

Example from Anthem Blue Cross covers both this explains the difference.

https://www11.anthem.com/ca/shared/f2/s2/t1/pw_g329161.pdf
 
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hey guys
trying to get further clarification these visits. i have a medicare patient due for annual, no pelvic exam was done, this guide says bill 99397 etc to the patient if thats the case.....but then i'm wondering....for the year between g0101 when they have an annual wellness visit shouldn't i charge the g0438 or g0439 to medicare instead of charging the 99397 to the patient? because they're supposed to cover an annual well woman exam right?

I'm so confused! here's the guide

file:///C:/Users/CKorb/Downloads/Guide%20to%20Billing%20the%20Medicare%20Annual%20Exam.pdf
 
It looks like the hyperlink you included is a file location for a download to your system, do you have the link to the actual website source for this document?

What I can say as someone who has worked in health insurance for 20+ years, is that some MA plans as part of their supplemental benefits will cover an actual preventive visit billed with 9938x-9939x. You are going to have to check the individua MA plans you contract with, not just the MA carrier but the actual plans as MA plans with an insurer can differ from each other. Of course, traditional Medicare Part B does not cover preventive E&M codes 9938x-9939x.

I'm unclear on your reference to G0101, is the patient being seen for a cervical or vaginal cancer screening, pelvic ad clinical breast exam? Or is the patient being seen for a preventative medicine E&M billed with 9938x-9939x, or even a Medicare AVW G0438 or G0439?

What exactly is the patient being seeing for or what services are you attempting to determine if the service is covered and whether you are referring to MA plans or traditional Medicare Part B?
 
I hope this works, here's the link again

https://www.aapc.com/discuss/attachments/2024-guide-to-billing-the-medicare-annual-exam-pdf.7020/

I work for an obgyn. Its a guide from a different post in the forum. Because I answer no to the first 2 scenarios because a pelvic exam wasn't done and i was told if a pelvic exam isn't done I can't charge the g0101.....(it's for a straight Medicare person for annual in their covered year amd perhaps they couldnt tolerate pelvic exam etc etc.) The guide tells me to bill 99397 etc to the patient because I answered no to pelvic exam but I don't see how that's fair that a patient now has to pay in their covered year when we did less work for the service now just because it was less work and the pelvic exam wasn't done. And if that's incorrect what should I be charging instead of the g0101 or what should I be charging

And then sometimes they come back for the year in-between for a general wellness exam in their non covered year. And the guide says to charge the 99397 etc but why not charge the other g code wellness visit codes I mentioned before?

Thanks so much just want to make sure I'm doing it right
 
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