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Billing Wellness Visits Under Medicare, Part III

Jul 24, 2023 | Newsletter

Billing Annual Wellness Visits Under Medicare, Part III

July 24, 2023

Last week, we delved deeper into the second of three types of wellness visits—Annual Wellness Visits (AWVs)—covered by Medicare. Now, let’s shift our focus to Subsequent Wellness Visits (along with addressing some of your questions).

Subsequent Wellness Visits (SWVs)

The first Annual Wellness Visit focuses on gathering information to create a Health Risk Assessment. During Subsequent Wellness Visits, which are also conducted annually, the aim is to update this information and the Health Risk Assessment. The code for Subsequent Wellness Visits is G0439, and it includes the same set of questions as the AWV. The patient is required to complete the same questionnaire as the previous year, and all the provided information must be reviewed and documented as updated.
It is important to update the medication lists and prior diagnoses as well. If a health condition no longer exists or is not current (e.g., cancer, cold, ear infection), it should be either removed or marked with a HISTORY status.

Here are the complete CMS guidelines for Wellness visits:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html

Now let’s address some frequently asked questions regarding AWVs and SWVs.

  1. Can I bill for mental health screenings during these visits?
    • Yes, but there are certain considerations. You can bill the PHQ-9 mental health screening using code G0444 (59) with both the AWV and SWV, but only if the patient
      answers all nine questions, meeting the required 15 minutes for billing the screening. If the patient stops at question 2, it is not billable as it does not meet the requirements. Additionally, MOLST 99497 can be separately billed for a duration of >16 to 30 minutes.
  2. When can you bill for a routine physical (99397) for a senior?
    • The billing eligibility depends on the patient’s insurance. According to Medicare regulations, routine physicals are not covered. If Medicare is the patient’s primary insurance and they have a commercial insurance policy as secondary, then bill for the AWV/SWV.
    • The billing eligibility depends on the patient’s insurance. According to Medicare. regulations, routine physicals are not covered. If Medicare is the patient’s primary insurance and they have a commercial insurance policy as secondary, then bill for the AWV/SWV.
    • If the senior adult has a Medicare replacement plan (such as Tufts Medicare Preferred, HMO Blue Medicare, or similar plans), either can be billed. Depending on the insurance, the patient can receive both the Medicare AWV and a routine physical, but not on the same day. Typically, these two visits would be scheduled at least six months apart.
  3. Now, let’s address the important question: Can we bill for an additional sick visit
    during wellness visits or routine physicals?

    • As always, the answer depends on the specific circumstances. Medicare wellness
      visits, including IPPEs, AWVs, and SWVs, are considered “hands-off” physical
      examinations. These visits primarily involve conversations, questions, and
      information gathering. They also include counseling and referrals to specialists.
    • In the case of these visits, the answer is yes: You can add an additional “sick” visit to
      the AWV if the patient addresses new or ongoing health issues and the healthcare
      provider addresses chronic or new issues.
    • However, when it comes to routine 99397 physicals for patients aged 65 or older, the situation becomes more complex. You can bill for an additional office visit only if (a) the health issue or problem is new or (b) a current issue is worsened or exacerbated. It is not permissible to add charges for stable health issues during the routine physical.

To revisit the beginning of this insightful journey, click the link below:

Billing Wellness Visits Under Medicare, Part I

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