JoAnne: Q: [Medicare Physicals] I would like to know more about coding a Medicare annual
& subsequent visit comparing to a regular physical which we all know Medicare does not
cover.
They cover 1 welcome to Medicare physical & then start with the annual or subsequent
visits.
A: This is probably the most confusing set of coding that I have found physicians to
experience.
For some reason when Medicare developed these procedure codes, they just assumed that this
was going to be a comprehensive physical checkup.
And it’s not at all; it’s mostly record keeping and making list of the patient’s
history and whatever.
When you bill for these codes, we have a number of them.
One of them is the Welcome to Medicare, which you would begin with the time you turn 65
and you have the year to see the doctor and they would bill a Welcome to Medicare, and
you don’t need a V70.0 as an annual physical exam, it is not necessary, any diagnosis will
do.
Like I said, it’s only from when you’re Medicare eligible for the first 12 months.
Then, when you have the year is passed, you go to what’s called an Annual Wellness Visit
and that’s G0438, that’s an Initial Annual Wellness Visit.
What I would recommend to people that do any billing and coding, go on to the Medicare
website, and get the status of where your patients are at because a lot of doctors will
bill for the Welcome to Medicare when a year has already passed or the patient may have
already seen another doctor, and so, you would have to jump to the next level of the G0438.
It’s 12 months after the Welcome to Medicare Visit and it is not physical exam.
The 99387 and 99397 are completely different and they’re not paid for by Medicare.
These are definitely wellness visits where they record a lot of the patient history and
they’re monitoring their health and focusing on preventive care.
After the G0438, the initial, then from that point on, once a year, you would have the
subsequent annual exam.
Now, Medicare says that you can go to about 11 months and see the doctor, let me tell
you I don’t know what your contractors are like and you’re all part of the country,
but I say 12 months 1 day, because you have enough appeals to deal with on a daily basis.
To fight Medicare for one month, I just say, wait a full year and go with it.
But again, any of these visits can be billed with a sick visit and again if you went in
for your annual wellness exam and you had a sore throat or an earache, you could also
bill like a level 2 or 3 depending and you would have the modifier-25 to the E/M code;
so you can bill a sick visit with the wellness visit.
Also, on the G0402, just to tell you that there is also an initial EKG and there are
three procedure codes defining three different types of EKGs and that is only the one time
you can use this code and it’s only with the G0402.
But just to add if the patient when they’re having their vitals checked or whatever because
they do have a little bit of a checkup.
The patient has palpitations or whatever, you are allowed to bill a regular EKG and
link it to a diagnosis code for medical necessity.
In addition to these three codes (G0402, G0438, G0439), you can also bill a pap and a pelvic
exam with these if that was part of the exam, again, that’s all relative to the visit.
But what I wanted to point out is that the criteria for each one of these is very different.
On the Welcome to Medicare Visit, the doctor or provider reviews the beneficiary’s medical
and social history.
They review the potential risk factors for depression and mood disorders.
They review the functional ability and level of safety.
The examination is the height, the weight, blood pressure, visual acuity, body mass index,
and other factors that are deemed appropriate.
That’s the exam.
The rest of it is all verbal and discussion.
They talk about end of life planning, there’s education and counseling involved, and referrals
based on the prior components I just mentioned.
And that’s it for patient had problems or whatever.
If you go on to the Medicare website, you can see a whole list of preventive visits
from colonoscopies, bone density, mammograms, and that could all be part of the referral
process for preventive services.
That’s covered in G0402.
Again, if this was already provided by someone, you’re going to get denied; so take the
extra step and check on the Medicare website, verify the eligibility, and see which one
of these the patient has already used.