Are you missing the initial annual wellness visit? | G0438

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.

Back to blog