Medicare Answers: Medicare Coding for an Annual Wellness Exam

  • Originally published June 24, 2013 , last updated December 23, 2014
  • Medicare
Medicare Answers: Medicare Coding for an Annual Wellness Exam

If you have a Medicare question you’d like answered, you can leave it in the comments section below, or you can email it to AskRoger@SeniorMarketSales.com.

This week’s question deals with Medicare coding for an annual wellness exam.

Jean Asks,

Any recommendation for a doctor who, when asked for a Medicare Annual Wellness exam, bills it as a 99397 Senior wellness exam, which Medicare declined because 99397 is no longer a qualifying Medicare code? The doctor's office says they don't have to have an ABN because Medicare never physicals. (Original Medicare w/ supplement F) Yes, appeal was filed and Medicare is asking for more records from the doctor but so far, the doctor's office is unwilling to consider filing differently and repeated the issue with another client.

After my last article, Jean was having problems with getting Medicare to pay for the Annual Wellness benefit. I sent some ideas such as getting SHIPP involved, which had already been tried. I was about to give up and then thought maybe more research could provide a solution.

Jean uses some numbers and acronyms that might be confusing to most. ABN stands for Advanced Beneficiary Notice of Non-coverage. The number 99397 is a coding number. I will say I am no claims analyst or expert in filing claims but that number might be the problem.

My research found that 99397 is coding for a comprehensive preventive visit and Medicare does not cover that exam thus the ABN.

Effective January 1, 2011, Medicare started to provide coverage for Annual Wellness Visits. This benefit was included in the Affordable Care Act of 2010. Medicare has come up with two new HCPCS codes for these well visits for medical billing purposes. The codes are G0438 and G0439.

When a Medicare patient first enrolls into Medicare, during their first year they can have a “Welcome to Medicare” exam, G0402. This exam must be done within 12 months of enrolling. The next year the patient can have an Annual Wellness Visit (AWV), G0438 first AWV. In the following years you will bill G0439 annually for the Subsequent Annual Wellness Visit.

Now if a patient has already had their “Welcome to Medicare” exam or if they are no longer eligible because it is beyond 12 months of enrolling into Medicare, then you can use the AWV G0438 for their first visit.

Please note there are different requirements for each visit type and that the Annual Wellness Visit is NOT a Routine Complete Physical Exam. It may still be appropriate to bill a 99387 or 99397 if that service is performed. The patient will be responsible for the fees as Medicare does not cover most routine preventive care.

Thank You,
Roger