To do or not to do? When can you report a problem oriented visit with the Welcome to Medicare (G0402), or Initial or Subsequent (G0438, G0439) Medicare Wellness Visits?
If the physician/NP/PA treats and documents 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. 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.
I’m raising this issue today because NGS published a FAQ (page 73) about the topic. I’m grateful to the client that sent to me, because I had missed it. I totally disagree with NGS’s reply.
Q: If a patient is scheduled for a follow up visit of several conditions, is it allowed for the provider to separately bill an Annual Wellness Visit performed on the same day?
A: If a patient has several chronic conditions, all of which are clinically stable, there is no medical necessity for an E&M service on the same day as the Annual Wellness visit (AWV), since a review of those conditions will be include in the AWV. A separate E&M service would only be medically necessary if the patient were to present for a scheduled AWV with signs and symptoms warranting separate assessment and clinical care.
This isn’t the first, and I’m sure won’t be the last time I disagree with a MAC’s interpretation of CMS’s rules. CMS itself does not use this language in their publications, and did not include this language in the Physician Fee Schedule Final Rule, when AWVs were implemented.
If NGS is your MAC, and a patient presents with stable problems at an E/M visit, don’t add a wellness visit to the service. There is the implication that if the patient presents for a wellness visit and all of the problems are stable, don’t add a problem-oriented E/M service either. If NGS is not your MAC, you don’t need to follow NGS’s interpretation.
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.
And once again, if it is all copied from a prior note, don’t bill it!
Reviewed, Betsy Nicoletti 10/12/2018