When can you report a problem oriented visit with the Welcome to Medicare (G0402), or Initial or Subsequent (G0438, G0439) Medicare Wellness Visits?
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
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!
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