It used to the be the case that the Medicare program focused on illness-care and chronic disease management. That has changed drastically over the past 8 years as coverage for wellness and preventative-care examinations are now included in Medicare benefits.
However, many providers are still not taking advantage of reimbursement for annual visits. The key behind these not-so-newly covered Medicare benefits is properly coding these wellness visits so that they are covered. Plus, if a patient complains of an additional issue during their annual visit, these should be coded separately and the provider can receive reimbursement for both the annual visit and the problem diagnosis.
Welcome to Medicare Visit
Coding for annual visits for Medicare Part B holders is unique. Billing for a wellness visit is not done using the normal wellness-exam CPT codes (99381-99397). These claims will be rejected as “non-covered services”. Instead, providers should use Medicare-only codes: G0438 for the initial visit and G0439 for subsequent visits.
The Initial Preventative Physical Examination (IPPE), commonly referred to as the “Welcome to Medicare Visit,” is a comprehensive exam a patient can have one time during the first 12 months of having Medicare Part B. The examination consists of seven components:
Certain screenings, flu and pneumococcal shots, and referrals for other care, if needed
Height, weight and blood pressure measurements
Calculation of body mass index (BMI)
A simple vision test
A review of potential risk factors for depression and level of safety
An offer to discuss advanced directives
A written plan letting the patient know which screenings, shots, and other preventative services they need
Coding for this initial exam is unique to Medicare. Though the diagnosis code (ICD-10 code) for the exam is Z00.00 (general physical exam), the CPT code for the visit is NOT the wellness-exam code range used by every other insurance plan (99381-99397). Instead, it is billed with a Medicare-only code, G0438.
Subsequent Annual Visits
In addition to the one-time available Welcome to Medicare visit, beneficiaries can also receive an annual wellness and prevention exam with no co-pay. Again, billing for these annual visits will be denied unless they use the Medicare-specific code G0439.
Additional Diagnosis
During their annual visit, a patient may present for a problem or issue unrelated to their wellness exam. For the problem diagnosis, the provider should bill an Evaluation and Management (E&M) code (99202-99204 for new patients or 99212-99215 for established patients) with a modifier 25. If the provider codes the visit and the unrelated problem in this manner, they will be reimbursed for BOTH the E&M and the annual visit. Note that the problem diagnosis would need to be attached to the E&M, while the dx Z00.00 covers the annual.
Providers can receive reimbursement for initial wellness exams, subsequent annual visits as well as simultaneous problem diagnosis if, and only if, all of the services are properly coded. Failure to use Medicare-specific codes for annual and wellness visits will result in denials. And, problem diagnosis that aren’t coded independently and attached to the E&M will not be reimbursed.