• My Account
    • Login
  • Contact Us

CodingIntel

Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

  • Join Today
  • What is CodingIntel
    • About
    • Become a Member
    • FAQ
  • Pricing
  • Free Resources
    • Overview
    • Blog
    • Everyday Coding Q&A
    • Newsletter
    • Can I get paid
  • Coding Library
    • Coding Guides
    • Quick Reference Sheets
    • E/M Services
    • How Physician Services Are Paid
    • Prevention & Screening
    • Care Management & Remote Monitoring
    • Surgery, Modifiers & Global
    • Diagnosis Coding
    • New & Newsworthy
    • Speciality
    • Practice Management
    • E/M Rules Archive
  • Webinars

March 29, 2023

Age and wellness visits | Eligibility for Welcome to Medicare

Print Friendly, PDF & Email
  • Knowing which Medicare wellness visit to bill
  • Eligibility requirements for the Welcome to Medicare visit

After I gave a presentation at a family medicine conference a physician said to me, “What you just told me will pay for the entire cost of my coming to this conference.” I don’t always hear that after I give a presentation.  Sometimes I hear the opposite.

Incorrect coding equals lost revenue

The mistake he was making that was costing him money is the same mistake I saw recently in a large primary care group.  It was billing a subsequent annual wellness visit when the patient was eligible for an initial annual wellness visit.

The physician, like the group I visited recently, billed the Welcome to Medicare visit in the first year the patient was enrolled in Medicare and then billed a subsequent wellness visit the next year. They missed the initial annual wellness visit.

The correct sequence is:

  • First, bill the Welcome to Medicare visit. The patient is eligible for this service within the first year of enrollment with Medicare.
  • Second, bill the initial annual wellness visit. The patient is eligible for this after 11 full months have passed since the Welcome to Medicare visit, or if they didn’t have the Welcome to Medicare visit in the first full year of enrollment.
  • Third, bill the subsequent annual wellness visit (after 11 four months have past and every year thereafter).

Why does it make such a big difference?

The payment for the initial annual wellness visit is much higher than the payment for the subsequent wellness visit.

Run a CPT® frequency report

My first suspicion that the group was billing these incorrectly was when I looked at the volume for these three visits. There weren’t many initial annual wellness visits.

If you are wondering if the primary care clinicians in your group and the coders understand this, run a frequency report that shows the number of times these three codes were billed. (G0402, G0438 and G0439)

If G0438 is billed less frequently than G0402, be suspicious.

How can a clinician know which visit to bill?

They can’t, without staff help. Staff can look this up, however.

https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp

I suggest using the same template for all three visits.

There are slight variations in the requirements, so develop a template that meets the requirements of both the Welcome to Medicare visit and the wellness visits.

  • G0402 requires the testing of visual acuity, and with patient permission, end-of-life planning
  • G0438 and G0439 require a list of current medical providers, a health risk assessment, and an assessment of cognitive function. The content of the health risk assessment is usually in the screening for the Welcome to Medicare visit.

This allows you to bill any one of the three visits based on the documentation.

Check your MACs website

Office staff can check their Medicare Administrative Contractor’s (MAC) website to determine which visit the patient is eligible for. Or, the CMS site above.

While it is true that this takes time to do and can be difficult in a busy practice, it saves the time of resubmitting claims that were denied.

Don’t miss billing the Initial Annual Wellness Visit!

CMS updated the MLN Matters article in October of 2020. You can find it https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html.

Age and wellness visits | Eligibility for Welcome to Medicare

Question:

Does the patient need to be 65 years old in order to bill the Welcome to Medicare Visit?

Answer:

This is almost a trick question. There is no age restriction for billing Medicare for the Welcome to Medicare visit, the initial annual wellness visit or the subsequent annual wellness visit. The patient is eligible for the Welcome to Medicare visit during the first year after enrolling in Medicare. Since most patients enroll at age 65, those patients are indeed eligible from age 65 to 66.

But, although we think of people being eligible for Medicare at age 65, there are many individuals who are eligible for Medicare at a younger age, because they have qualified for Social Security Disability Insurance (SSDI). A patient is eligible for Medicare after 24 months on SSDI. And, other patients for whom Medicare is a Secondary Payer, because they continue to work.

Medicare’s “Medicare Wellness Visits” resource says this about the IPPE, or “Welcome to Medicare” visit,

  • Medicare pays for one patient IPPE per lifetime not later than the first 12 months after the patient’s Medicare Part B benefits eligibility date.
  • Medicare pays the IPPE costs if the provider accepts assignment.
  • The eligibility for the service is based on the patient’s enrollment in Medicare, not age.

This is what is says about eligibility for Annual Wellness Visit services: “Medicare covers an AWV that delivers Personalized Prevention Plan Services (PPPS) for patients who:

  • Are no longer within 12 months after the patient’s Medicare Part B benefits eligibility date
  • Did not get an IPPE or AWV within the past 12 months”

Citations:

Medicare Wellness Visits MLN resource

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html

Additional resources:

  • Preventive Medicine Services – Medicare
  • Preventive medicine and Medicare wellness with E/M | Webinar

Back to blog

Get more tips and coding insights from coding expert Betsy Nicoletti.

Subscribe and receive our FREE monthly newsletter and Everyday Coding Q&A.

Sign up

We will never share your email address. Unsubscribe anytime.

Relevant Search Terms: Medicare, wellness visits, Welcome to Medicare, lost revenue, G0402, G0438, G0439, revenue initial annual wellness visit G0438

Last revised February 13, 2023 - Betsy Nicoletti
Tags: preventive services for medicare, primary care_preventive services

CPT®️️ is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.

2023 E/M reference sheets

These handy quick reference sheets included at-a-glance MDM requirements for office, hospital, nursing home and home and residence services. And, a bonus sheet with typical time for those code sets. Sign up for Betsy’s monthly newsletter to download these reference sheets and share them with your practitioners.

Sign Up Now

2023 E/M guidelines for hospital, nursing facility, home and residence services | Webinar

Effective January 1, 2023, the AMA has revised the definitions and guidelines for hospital and other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. Also, coding for prolonged care services gets another overhaul with revised codes and guidelines. Watch this webinar about all these changes.

Watch it now

Latest Intel

Coding for hospital services | Webinar

Coding for hospital services April 20, 2023 … Read More...

CMS Split/Shared Services Rules | Reference Sheet

Download Reference Sheet Split/shared services … Read More...

Chronic Care Management | Reference Sheet

This quick reference sheet includes clinical staff … Read More...

Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse | HCPCS Code G0442

The  US Preventive Services Task Force (USPSTF) … Read More...

Browse By Categories

Browse Content

  • Articles
  • Coding Guides
  • Everyday Coding Q&A
  • Videos
  • Can I Get Paid to
  • Blog
  • Webinars

Tags

behavioral health_cpt codes behavioral health_E/M services care management CMS updates Code sets and reimbursement compliance issues CPT codes for preventive services CPT updates critical care services dermatology_essential resource dermatology_procedures E/M frequency data E/M medical decision making E/M overview E/M reference sheets FQHC general surgery_diagnosis coding general surgery_E/M services general surgery_modifiers general surgery_procedures global surgery issues HCC diagnosis coding hospital inpatient/observation ICD-10 coding level of service_history level of service_MDM level of service_time medicare incident-to and shared services minor procedures modifiers newborn care office and other E/M Preventive and problem visits preventive services for medicare primary care_diagnosis coding primary care_E/M services primary care_essential resource primary care_modifiers primary care_other E/M services primary care_preventive services primary care_procedures remote physiologic monitoring screening and counseling for behavioral conditions teaching physician rules telehealth

All content on CodingIntel is copyright protected. Any resource shared within the permissions granted here may not be altered in any way, and should retain all copyright information and logos.

  • What is CodingIntel
  • FAQs
  • Terms of Use
  • Privacy Policy
  • Contact

Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

Copyright © 2023, CodingIntel
Privacy Policy