Reporting a Problem-Oriented Visit on the Same Day as Welcome to Medicare (G0402) or Initial and Subsequent Wellness Visit (G0438, G0439)

• I continue to hear that some consultants and coders don’t agree with reporting a problem oriented visit with welcome to Medicare or wellness visit
• The 2024 Physician Fee Schedule Final Rule commented on this

What does CMS say about adding an E/M service to a Welcome to Medicare visit or annual wellness visit?

About the Welcome to Medicare visit

When you furnish a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service along with the IPPE, Medicare may pay for the additional service. Report the additional Current Procedural Terminology (CPT) code (99201–99215) with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.[1]

About the Annual Wellness Visit

When you furnish a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service along with the AWV, Medicare may pay for the additional service. Report the additional Current Procedural Terminology (CPT) code with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.[2]

From the 2024 Physician Fee Schedule Final Rule

And, in the 2024 Physician Fee Schedule Rule, in a discussion of initiating visits for Community Health Integration CMS says, “Further, we believe that practitioners would normally bill an E/M visit in addition to the AWV when medical problems are addressed in the course of an AWV encounter, in accordance with our manual policy providing that a medically necessary E/M visit may be billed when furnished on the same occasion as an AWV in those circumstances (Chapter 12, Section 30.6.1.1.H of the Medicare Claims Processing Manual (Pub, 100-04).”[3]

And, “We continue to believe that when an AWV involves diagnosis or treatment of injury or illness to the degree that would warrant subsequent furnishing and billing of CHI to remove barriers significantly limiting the treatment plan, in most cases, an E/M visit would be separately billed.” [4]

CMS appears to be saying that when a Medicare beneficiary requires diagnosis or treatment of an illness, they expect a separate E/M service to be reported.

[1] ABCs of the Initial Preventive Physical Exam (IPPE) , ICN 006904 April 2017 p. 5

[2] ABCs of  the Annual Wellness Visit, ICN 905706 April 2017 p. 10

[3] CMS 2024 Physician Fee Schedule Final Rule, p. 309

[4] CMS 2024 Physician Fee Schedule Final Rule, p. 313

If you’ve read anything I’ve written on this topic or watched my videos, you know my opinion:

If the physician/NP/PA treats and documents and manages an acute or chronic problem during the same encounter as a wellness visit, bill both a Welcome to Medicare or Wellness Visit on the same day (hereafter referred to in shorthand as “wellness visits”). Reviewing significant, stable chronic problems counts. The note should show that the condition was reviewed and assessed, especially if there is no change in treatment. I do add a caveat: if the information about the chronic conditions is imported/copied from a prior note with barely an update, then don’t bill for the problem-oriented visit.

One MAC’s Q&A

From NGS:

Q: When a patient is scheduled for a follow up visit of several chronic conditions, is it allowed for the provider to separately bill Annual Wellness Visit performed on the same day?
Answer: Some chronic, stable conditions may not require assessment beyond the AWV, while others may require additional clinical examination and review or changes to the plan of care. This decision is within the realm of the performing provider’s clinical judgement. When additional history, examination and MDM is indicated to fully assess a patient’s clinical status, a separate E/M service may be performed and billed. Documentation of the E/M visit should clearly support the medical necessity of the separate service. Added 2/20/2020

Q: When is an E/M service separately payable on the same DOS as the AWV?

Answer: The AWV has been designed as an annual overview of the patient’s health status, including elements of physical and mental health and general safety. It may be performed by clinical staff under physician or NPP supervision, and includes a review of known chronic conditions.

In some situations, the patient’s chronic (or acute) condition(s) may require evaluation and management by the primary health care provider (physician or NPP). Documentation for these services may be included in one note or in two separate notes, based on the provider’s preference. Of note, the documentation must clearly delineate all necessary details of the AWV and all necessary elements of the E/M service relative to medical necessity and level of coding. Updated 2/20/2020

This NGS answer in a nutshell: sometimes yes, sometimes no.

If one of the patient’s conditions is not stable (as noted in the HPI, exam, assessment and treatment plan), or, an acute problem is addressed, then do add a problem-oriented visit at the time of the wellness visit. Document the symptoms or the status of the condition in the HPI. If the HPI does not describe the conditions, don’t bill an E/M. The treatment plan should show either a change in treatment or a plan to monitor the condition.

Keep in mind the revised E/M guidelines for codes 99202–99215. Code selection for these office and other outpatient visits is based on time or medical decision making. History and exam are no longer key components in code selection. That makes it easier to meet the code requirements for a problem oriented visit. In my opinion, it is more defensible if the history describes either HPI symptoms for an acute problem or the status of chronic conditions.

And once again, if it is all copied from a prior note, don’t bill it!