well visit billing codes

Medicare Wellness Visits Back to MLN Print November 2023 Updates

What’s Changed?

• Added information about monthly chronic pain management and treatment services
• Added information about checking for cognitive impairment during annual wellness visits
• Added information about Social Determinants of Health Risk Assessments as an optional element of annual wellness visits

Quick Start

The Annual Wellness Visits video helps you understand these exams, as well as their purpose and claim submission requirements.

Medicare Physical Exam Coverage

Initial Preventive Physical Exam (IPPE)

Review of medical and social health history and preventive services education.

✔ New Medicare patients within 12 months of starting Part B coverage

✔ Patients pay nothing (if provider accepts assignment)

Annual Wellness Visit (AWV)

Visit to develop or update a personalized prevention plan and perform a health risk assessment.

✔ Covered once every 12 months

Routine Physical Exam

Exam performed without relationship to treatment or diagnosis of a specific illness, symptom, complaint, or injury.

✘ Medicare doesn’t cover a routine physical

✘ Patients pay 100% out-of-pocket

Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health :

• Health Equity Technical Assistance Program
• Disparities Impact Statement

Communication Avoids Confusion

As a health care provider, you may recommend that patients get services more often than we cover or that we don’t cover. If this happens, help patients understand they may have to pay some or all costs. Communication is key to ensuring patients understand why you’re recommending certain services and whether we cover them.

Initial Preventive Physical Exam

The initial preventive physical exam (IPPE), also known as the “Welcome to Medicare” preventive visit, promotes good health through disease prevention and detection. We pay for 1 IPPE per lifetime if it’s provided within the first 12 months after the patient’s Part B coverage starts.

1. Review the patient’s medical and social history

At a minimum, collect this information:

• Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments)
• Current medications, supplements, and other substances the person may be using
• Family history (review the patient’s family and medical events, including hereditary conditions that place them at increased risk)
• Physical activities
• Social activities and engagement
• Alcohol, tobacco, and illegal drug use history

Learn information about Medicare’s substance use disorder (SUD) services coverage .

2. Review the patient’s potential depression risk factors

Depression risk factors include:

• Current or past experiences with depression
• Other mood disorders

Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. APA’s Depression Assessment Instruments has more information.

3. Review the patient’s functional ability and safety level

Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the patient’s:

• Ability to perform activities of daily living (ADLs)
• Hearing impairment
• Home and community safety, including driving when appropriate

Medicare offers cognitive assessment and care plan services for patients who show signs of impairment.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), blood pressure, balance, and gait
• Visual acuity screen
• Other factors deemed appropriate based on medical and social history and current clinical standards

5. End-of-life planning, upon patient agreement

End-of-life planning is verbal or written information you (their physician or practitioner) can offer the patient about:

• Their ability to prepare an advance directive in case an injury or illness prevents them from making their own health care decisions
• If you agree to follow their advance directive
• This includes psychiatric advance directives

6. Review current opioid prescriptions

For a patient with a current opioid prescription:

• Review any potential opioid use disorder (OUD) risk factors
• Evaluate their pain severity and current treatment plan
• Provide information about non-opiod treatment options
• Refer to a specialist, as appropriate

The HHS Pain Management Best Practices Inter-Agency Task Force Report has more information. Medicare now covers monthly chronic pain management and treatment services .

7. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them to treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

8. Educate, counsel, and refer based on previous components

Based on the results of the review and evaluation services from the previous components, provide the patient with appropriate education, counseling, and referrals.

9. Educate, counsel, and refer for other preventive services

Include a brief written plan, like a checklist, for the patient to get:

• A once-in-a-lifetime screening electrocardiogram (ECG), as appropriate
• Appropriate screenings and other covered preventive services

Use these HCPCS codes to file IPPE and ECG screening claims:

Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment

Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv

* Section 60.2 of the Medicare Claims Processing Manual, Chapter 9 has more information on how to bill HCPCS code G0468.

Report a diagnosis code when submitting IPPE claims. We don’t require you to use a specific IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an IPPE when performed by a:

• Physician (doctor of medicine or osteopathy)
• Qualified non-physician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist)

When you provide an IPPE and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

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IPPE Resources

• 42 CFR 410.16
• Section 30.6.1.1 of the Medicare Claims Processing Manual, Chapter 12
• Section 80 of the Medicare Claims Processing Manual, Chapter 18
• U.S. Preventive Services Task Force Recommendations

No. The IPPE isn’t a routine physical that some patients may get periodically from their physician or other qualified non-physician practitioner (NPP). The IPPE is an introduction to Medicare and covered benefits, and it focuses on health promotion, disease prevention, and detection to help patients stay well. We encourage providers to inform patients about the AWV during their IPPE. The Social Security Act explicitly prohibits Medicare coverage of routine physical exams.

No. The IPPE and AWV don’t include clinical lab tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.

No. We waive the coinsurance, copayment, and Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening electrocardiogram (ECG) (HCPCS codes G0403, G0404, or G0405).

A patient who hasn’t had an IPPE and whose Part B enrollment began in 2023 can get an IPPE in 2024 if it’s within 12 months of the patient’s Part B enrollment effective date.

We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, find your MAC’s website .

Annual Wellness Visit Health Risk Assessment

The annual wellness visit (AWV) includes a health risk assessment (HRA). View the HRA minimum elements summary below. A Framework for Patient-Centered Health Risk Assessments has more information, including a sample HRA.

Perform an HRA

• You or the patient can update the HRA before or during the AWV
• Consider the best way to communicate with underserved populations, people who speak different languages, people with varying health literacy, and people with disabilities
• Demographic data
• Health status self-assessment
• Psychosocial risks, including, but not limited to, depression, life satisfaction, stress, anger, loneliness or social isolation, pain, suicidality, and fatigue
• Behavioral risks, including, but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (for example, seat belt use), and home safety
• Activities of daily living (ADLs), including dressing, feeding, toileting, and grooming; physical ambulation, including balance or fall risks and bathing; and instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, transportation, shopping, managing medications, and handling finances

1. Establish the patient’s medical and family history

At a minimum, document:

• Medical events of the patient’s parents, siblings, and children, including hereditary conditions that place them at increased risk
• Use of, or exposure to, medications, supplements, and other substances the person may be using

2. Establish a current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure
• Other routine measurements deemed appropriate based on medical and family history

4. Detect any cognitive impairments the patient may have

Check for cognitive impairment as part of the first AWV.

Assess cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others. Consider using brief cognitive tests, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Alzheimer’s and Related Dementia Resources for Professionals has more information.

5. Review the patient’s potential depression risk factors

6. Review the patient’s functional ability and level of safety

• Ability to perform ADLs

7. Establish an appropriate patient written screening schedule

Base the written screening schedule on the:

• Checklist for the next 5–10 years
• United States Preventive Services Task Force and Advisory Committee on Immunization Practices (ACIP) recommendations
• Patient’s HRA, health status and screening history, and age-appropriate preventive services we cover

8. Establish the patient’s list of risk factors and conditions

• A recommendation for primary, secondary, or tertiary interventions or report whether they’re underway
• Mental health conditions, including depression, substance use disorders , suicidality, and cognitive impairments
• IPPE risk factors or identified conditions
• Treatment options and associated risks and benefits

9. Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs

Include referrals to educational and counseling services or programs aimed at:

• Fall prevention
• Physical activity
• Tobacco-use cessation
• Social engagement
• Weight loss

10. Provide advance care planning (ACP) services at the patient’s discretion

ACP is a discussion between you and the patient about:

• Preparing an advance directive in case an injury or illness prevents them from making their own health care decisions
• Future care decisions they might need or want to make
• How they can let others know about their care preferences
• Caregiver identification
• Advance directive elements, which may involve completing standard forms

Advance directive is a general term that refers to various documents, like a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. The Advance Care Planning fact sheet has more information.

We don’t limit how many times the patient can revisit the ACP during the year, but cost sharing applies outside the AWV.

11. Review current opioid prescriptions

• Review any potential OUD risk factors
• Provide information about non-opioid treatment options

12. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them for treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

13. Social Determinants of Health (SDOH) Risk Assessment

Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and ensure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate.

1. Review and update the HRA

2. Update the patient’s medical and family history

At a minimum, document updates to:

3. Update current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including those added because of the first AWV personalized prevention plan services (PPPS), and any behavioral health providers.

• Weight (or waist circumference, if appropriate) and blood pressure

5. Detect any cognitive impairments patients may have

Check for cognitive impairment as part of the subsequent AWV.

6. Update the patient’s written screening schedule

Base written screening schedule on the:

7. Update the patient’s list of risk factors and conditions

• Mental health conditions, including depression, substance use disorders , and cognitive impairments
• Risk factors or identified conditions

8. As necessary, provide and update patient PPPS, including personalized health advice and appropriate referrals to health education or preventive counseling services or programs

9. Provide advance care planning (ACP) services at the patient’s discretion

10. Review current opioid prescriptions

11. Screen for potential substance use disorders (SUDs)

12. Social Determinants of Health (SDOH) Risk Assessment

Preparing Eligible Patients for their AWV

Help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment:

• Medical records, including immunization records
• Detailed family health history
• Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
• Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists

Use these HCPCS codes to file AWV claims:

Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

Report a diagnosis code when submitting AWV claims. We don’t require you to use a specific AWV diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an AWV if performed by a:

• Medical professional (including health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of medical professionals directly supervised by a physician

When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV, and G0439 is for subsequent AWVs. Don’t bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. We deny these claims with messages indicating the patient reached the benefit maximum for the time period.

Medicare telehealth includes HCPCS codes G0438 and G0439.

ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a patient to discuss their health care wishes and medical treatment preferences if they become unable to communicate or make decisions about their care. At the patient’s discretion, you can provide the ACP during the AWV.

Use these CPT codes to file ACP claims as an optional AWV element:

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Report a diagnosis code when submitting an ACP claim as an optional AWV element. We don’t require you to use a specific ACP diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

We waive both the Part B ACP coinsurance and deductible when it’s:

• Provided on the same day as the covered AWV
• Provided by the same provider as the covered AWV
• Billed with modifier 33 (Preventive Service)
• Billed on the same claim as the AWV

We waive the ACP deductible and coinsurance once per year when billed with the AWV. If we deny the AWV billed with ACP for exceeding the once-per-year limit, we’ll apply the ACP deductible and coinsurance .

We apply the deductible and coinsurance when you deliver the ACP outside the covered AWV. There are no limits on the number of times you can report ACP for a certain patient in a certain period. When billing this service multiple times, document changes in the patient’s health status or wishes about their end-of-life care.

SDOH is important in assessing patient histories; in assessing patient risk; and in guiding medical decision making, prevention, diagnosis, care, and treatment. In the CY 2024 Medicare Physician Fee Schedule final rule , we added a new SDOH Risk Assessment as an optional, additional element of the AWV. At both yours and the patient’s discretion, you may conduct the SDOH Risk Assessment during the AWV.

Use this HCPCS code to file SDOH Risk Assessment claims as an optional AWV element:

Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes

Report a diagnosis code when submitting an SDOH Risk Assessment claim as an optional AWV element. We don’t require you to use a specific SDOH Risk Assessment diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

The implementation date for SDOH Risk Assessment claims is July 1, 2024. We waive both the Part B SDOH Risk Assessment coinsurance and deductible when it’s:

We waive the SDOH Risk Assessment deductible and coinsurance once per year when billed with the AWV.

If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when you deliver the SDOH Risk Assessment outside the covered AWV.

AWV Resources

• 42 CFR 410.15
• Section 140 of the Medicare Claims Processing Manual, Chapter 18

No. The AWV isn’t a routine physical some patients may get periodically from their physician or other qualified NPP. We don’t cover routine physical exams.

No. We waive the coinsurance, copayment, and Part B deductible for the AWV.

We cover an AWV for all patients who’ve had Medicare coverage for longer than 12 months after their first Part B eligibility date and who didn’t have an IPPE or AWV within those past 12 months. We cover only 1 IPPE per patient per lifetime and 1 additional AWV every 12 months after the date of the patient’s last AWV (or IPPE). Check eligibility to find when a patient is eligible for their next preventive service.

Generally, you may provide other medically necessary services on the same date as an AWV. The deductible and coinsurance or copayment applies for these other medically necessary and reasonable services.

You have different options for accessing AWV eligibility information depending on where you practice. Check eligibility to find when a patient is eligible for their next preventive service. Find your MAC’s website if you have specific patient eligibility questions.

Know the Differences

An IPPE is a review of a patient’s medical and social health history and includes education about other preventive services .

• We cover 1 IPPE per lifetime for patients within the first 12 months after their Part B benefits eligibility date
• We pay IPPE costs if the provider accepts assignment

An AWV is a review of a patient’s personalized prevention plan of services and includes a health risk assessment.

• We cover an annual AWV for patients who aren’t within the first 12 months after their Part B benefits eligibility date
• We cover an annual AWV 12 months after the last AWV’s (or IPPE’s) date of service
• We pay AWV costs if the provider accepts assignment

A routine physical is an exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.

• We don’t cover routine physical exams, but the IPPE, AWV, or other Medicare benefits cover some routine physical elements
• Patients pay 100% out of pocket

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Education, trainings and manuals, regulations, news and insights, annual wellness visit (awv) documentation and coding.

A Medicare Annual Wellness Visit (AWV) is not a typical physical exam. Rather, it’s an opportunity to promote quality, proactive, cost-effective care. AWVs help you engage with your patients and increase revenue.

A physician, PA, NP, certified clinical nurse specialist or a medical professional under the direct supervision of a physician (including health educators, registered dietitians and other licensed practitioners) can perform AWVs.

AWV documentation

Document all diagnoses and conditions to accurately reflect severity of illness and risk of high-cost care.

An ICD-10 Z code is the first diagnosis code to list for wellness exams to ensure that member financial responsibility is $0.

• Z00.00 — encounter for general adult medical examination without abnormal findings
• Z00.01 — encounter for general adult medical examination with abnormal findings

The two CPT® codes used to report AWV services are:*

• G0438 — initial visit**
• G0439 — subsequent visit (no lifetime limits)

Additional services (lab, X-rays, etc.) ordered during an AWV may be applied toward the patient’s

deductible and/or be subject to coinsurance. Before performing additional services, discuss them

with the patient to verify that the patient understands their financial responsibilities.

More information

For additional information and education, contact us at  [email protected] .

*CPT® is a registered trademark of the American Medical Association.

**Code G0438 is for the first AWV only. The submission of G0438 for a beneficiary for which a claim code of G0438 has already been paid will result in a denial.

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• CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.
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• In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. 

See CMS's Medicare Coverage Center

• Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change.
• Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.
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See Aetna's External Review Program

• The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT®), copyright 2015 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
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CPT Codes for Annual Wellness Visits

Annual Wellness Visits (AWV) are a type of preventive care for Medicare patients. There are many benefits to implementing this type of program, such as improving patient outcomes and filling in gaps in care. However, you must understand the CPT billing codes to ensure your claims are not denied and help drive revenue at your organization.

What Is the CPT Code for Annual Wellness Visits?

There are generally three codes associated with Annual Wellness Visits representing distinct phases in AWV programs:

• G0402:  This code applies to the Welcome to Medicare visit — also referred to as an Initial Preventive Physical Exam (IPPE). This exam is not an Annual Wellness Visit, but it is valuable for understanding the framework of an AWV program. A patient is only eligible for the first 12 months they are enrolled in Medicare. This one-time visit focuses on gaining a general understanding of health with a vision screen, vital measurements and other assessments. This code will be rejected if you apply it after the 12-month mark of enrollment.
• G0438:  After 12 months of being enrolled in Medicare, a patient becomes eligible for their initial Annual Wellness Visit. If a patient completes an IPPE, they are permitted to use this initial visit on the first day of the same calendar month the next year. When a patient does not complete IPPE, this code will apply any time after the 12-month mark.
• G0439:  You must use this code for all Annual Wellness Visits following the initial one. Among the AWV codes, this is the last one you will use, and it's the only one you will use repeatedly. 

There are various factors that define an Annual Wellness Visit. There are even differentiators between the initial AWV and all subsequent AWVs. However, you should first make sure you understand the difference between  an Annual Wellness Visit and an annual physical .

Requirements and Components for Billing AWV

The requirements and components for an AWV vary based on whether you apply G0438 or G0439.

The G0438 requirements include:

• A Health Risk Assessment (HRA)
• Medical and family history
• List of current providers involved in the patient's health
• Cognitive function assessment
• Blood pressure, height, weight, body mass index and other appropriate measurements
• Risk factors for depression
• Functional ability and safety assessment
• Screening schedule creation
• Risk factors and conditions
• Personalized health advice
• Advance Care Planning, if desired

The G0439 requirements involve updating all of the above factors. Additionally, the patient must not have received an Annual Wellness Visit in the last 12 months. 

Who Can Bill AWV Codes?

Unlike some other billing codes under CMS, Annual Wellness Visit billing does have some flexibility. Practices do not need to hire additional staff for their AWV program, and physicians do not have to be the only professionals involved. Rather than assigning specific tasks and responsibilities to different team members, CMS allows for AWV coverage with any of the following individuals:

• A physician
• A physician assistant (PA)
• A nurse practitioner (NP)
• A certified clinical nurse specialist (CNS)
• A medical professional or team under a physician's supervision, such as registered dieticians or health educators

AWV billing is also not limited to primary care providers. Select specialty practices can bill for AWVs, such as neurology and cardiology. Regardless of who bills the AWV with CMS, a person is only permitted to receive one AWV per year. For instance, a cardiologist cannot bill for an AWV two months after a primary care provider did — the claim will be denied.

It's not unusual for Medicare patients to see one or more specialists, which can lead to AWV billing conflict. Having a real-time system in place to check eligibility can be a major advantage to all care providers.

Additional AWV Codes

At ChartSpan, we provide eligibility checks for G0438 and G0439 — the core codes for Annual Wellness Visits. However, some AWVs may involve additional codes depending on a patient's needs. Examples of additional codes include:

• 99497:  Advance Care Planning is an optional element of an AWV, and it includes a discussion about advance directives and other care wishes. The co-pay is waived when it's billed on the same day as an AWV.
• G0442 and G0443:  These codes must be used together, and they apply to an Annual Alcohol Screening and 15-minute alcohol counseling session, respectively.
• G0477:  This code is for a 15-minute obesity counseling session and it can be billed with IPPE or an AWV. 
• G0153 and G0154:  When an AWV takes longer than the typical service, these codes can be added for prolonged preventive services. The codes represent an extra 30 minutes and an additional 60 minutes, respectively.

Talking About AWV With Medicare Patients

Introducing an AWV program at your practice can help you shift from the  Fee-for-Service model to Value-Based Care (VBC) . AWV programs contribute to the VBC model because your practice receives payments based on patient health outcomes. Since AWVs are a form of preventive care, you can identify risk factors in your Medicare patients and take action on those factors to improve patient outcomes and close gaps in care.

The VBC model offers benefits to all parties involved in the healthcare system. Patients spend less to maintain their health, and providers can increase patient satisfaction to keep them coming back for appointments. While practices have to spend more time on preventive care, the time saved on chronic disease management is meaningful. Payers then reduce risks and have stronger cost controls. 

When discussing the Annual Wellness Visit with your patients, remind them that this type of preventive care reduces the risk of more severe disease and can improve their quality of life in the long term. 

Grow Your Medicare AWV Program With ChartSpan

Annual Wellness Visits offer advantages at many stages in the healthcare system, but they still come with challenges. The greatest hurdle your practice faces is patient eligibility. With specialists and primary care providers capable of billing for these visits, a patient may have already had an AWV without you knowing. Providing AWV services and being denied can diminish the value of the program itself.

At ChartSpan, we have a software solution that supports eligibility checks for your AWV program.  RapidAWV™  starts by identifying eligible Medicare patients as they come in for their regularly scheduled appointments. From there, the system checks the HIPAA Eligibility Transaction System (HETS) to determine if a patient has had an AWV with any other provider.

This process allows providers to bill for an AWV when they can guarantee reimbursement rather than being denied following a claim. With our team supporting this function through patient engagement and interaction, your overall approach to billing and care becomes more efficient. Improve patient outcomes, close gaps in care and introduce a VBC model with ease. 

Learn more about ChartSpan  or  contact us  to get started with our software.

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A Wellness Pros Guide to the What, Why, and How of CPT Codes

October 17, 2023

Health and wellness professionals who bill insurance or third-party payers directly, or provide Superbills to clients, need to be well-versed in Current Procedural Terminology (CPT) codes.

Accurate use of these codes is critical for successful billing and reimbursement. These codes are also important for documenting healthcare services provided to patients.

Even wellness pros who are paid directly by clients may need to be up to speed on CPT codes. That’s because local regulations and licensing boards may have specific requirements to use CPT codes for the purposes of record-keeping and documentation. 

With CPT codes changing yearly, staying up to date is critical. Keep reading for your complete CPT code primer, including how they’re structured, who maintains them, how they differ from other medical codes, and where to find the most up-to-date codes.

Key Takeaways

• CPT codes are used to report surgical and medical procedures and services and diagnostic services. They are critical for accurate reporting and reimbursement.
• There are three categories of CPT codes plus modifiers to provide additional information. CPT codes are different from ICD-10 codes and have some overlap with HCPCS codes.
• The American Medical Association’s CPT Editorial Panel is responsible for revising, updating, and modifying CPT codes, descriptors, rules and guidelines.

Understanding Current Procedural Terminology (CPT) Codes: The Basics

CPT codes are a standardized set of codes used to describe medical, surgical, and diagnostic services provided to patients in the U.S. healthcare system.

Developed and maintained by the American Medical Association (AMA), CPT codes are essential for billing and reimbursement through health insurance providers. 

For health and wellness practitioners who operate within the traditional U.S. reimbursement and billing system, these codes can cover services like evaluations, consultations, therapeutic interventions, and more.

CPT Code Structure

A CPT code typically consists of three parts:

• Numeric Code. CPT codes begin with a five-digit numeric code. This code is the core identifier for a specific medical procedure or service.
• Modifier. Some CPT codes may include one or more two-digit modifiers. Modifiers provide additional information about the service or procedure performed. For example, modifiers can indicate that a procedure was performed on the left or right side of the body or that multiple procedures were performed during the same session.
• Description. Each CPT code is associated with a description that explains what the code represents. This allows healthcare providers and payers to understand the nature of any service provided.

CPT vs. ICD Codes

In the simplest terms, CPT codes describe things like procedures and services and ICD codes describe diagnoses and conditions. 

ICD stands for International Statistical Classification of Diseases. ICD-10 codes are maintained and updated by the World Health Organization (WHO) and used around the globe for the purposes of health recording and statistics.

In the U.S. ICD-10-CM codes are standard, where the CM stands for “Clinical Modification.” These codes include additional clinical details and specificity, making them more suitable for clinical and billing purposes within the U.S. healthcare system.

Types of CPT Codes: A Closer Look

CPT codes are divided into three main categories: Category I, II and III.

Category I CPT Codes

Category I codes are the most commonly used CPT codes for the purposes of billing and documentation. They describe a vast array of medical procedures, diagnostic tests, office visits, and treatments relevant to healthcare providers and wellness professionals. 

For example, CPT code 97802 is a Category I code that represents “Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes.” Registered dietitians and nutrition professionals use this code to bill for their services when providing individualized medical nutrition therapy to patients.

Category II CPT Codes

Category II codes are supplementary codes used for performance measurement and quality reporting. They are not used for billing. Rather, these codes help with data collection for quality reporting and research.

While wellness professionals won’t commonly use Category II codes in their day-to-day practice, they may use them in situations where they are participating in quality improvement initiatives or research. 

For example, Category II CPT code 3008F is used for the documentation of body mass index (BMI) in adults. Specifically, it is used to indicate that healthcare providers have documented an adult patient’s BMI as part of the patient’s medical record. 

Category III CPT Codes

Category III codes are temporary codes used with emerging technologies and services that don’t yet have established Category I codes.

These codes allow providers, payers, and researchers to track the use of and outcomes related to new and experimental treatments or technologies. They are often used in clinical trials or when new procedures are in the early stages of adoption.

It’s unlikely that wellness pros would use Category III codes, but it could be possible. For example, someone who is involved in clinical research or trials that involve novel wellness interventions or technologies might use these codes to document and track the specific procedures or services they are providing as part of the study.

The Role of Medical Coders in CPT Coding

Although health and wellness practitioners may engage in coding-related tasks when billing for their services, they are not considered full-fledged medical coders. 

Medical coding is a distinct profession with its own formal education, training, and certification requirements. The role specifically involves accurately assigning codes to care services and procedures. 

Challenges Faced by Medical Coders

Medical coding professionals must continuously update their skills and knowledge to ensure accurate coding and compliance with healthcare regulations.

• Regulations are always changing. Medical coders must keep up with evolving healthcare regulations and changes in payer policies and compliance requirements.
• Data security and privacy. The Health Insurance Portability and Accountability Act (HIPAA) regulations mandate protecting the security and privacy of patient health information. Medical coders must comply with the Health Insurance Portability and Accountability Act .
• Audits and compliance. Medical coders are under the constant pressure that insurance companies or government agencies can perform a coding audit at any time to ensure accuracy and compliance with billing and coding standards.

Importance of Accurate Coding for Medical Procedures

Accurate coding means proper reimbursement. When codes are incorrect or lack specificity, it can lead to underpayment, delayed payments, or even non-payment by insurance companies. 

Although getting paid correctly and on time matters a lot, it’s important to know that coding errors can also impact patient care, legal compliance, data quality, research, and healthcare quality improvement. It plays a central role in the integrity and effectiveness of healthcare providers and the system as a whole.

Category I CPT codes are updated annually and effective for use on January 1 of a new calendar year. The updates may include the addition of new codes, revisions to existing codes, and deletions of obsolete codes. Staying current with these changes will help with accurate coding.

CPT Modifiers: Adding Context to Codes

Modifiers are added to Current Procedural Terminology codes to provide additional information. They indicate that a service or procedure performed has been altered, yet the definition of the service hasn’t changed. 

CPT modifiers are added to the end of a CPT code with a hyphen. When using more than one modifier, list the modifier that most impacts reimbursement first. The informational modifier can go second. 

Types of CPT Modifiers

Modifiers are typically either composed of two digits or two alphanumeric characters. 

• Two-digit modifiers consist of two numbers. They provide specific information about the service or procedure, such as indicating that a separate and distinct service was performed, or that a service was repeated.For example, if a dietitian used CPT code 97803 to get reimbursed for nutrition counseling, but she provided the service via Telehealth, then she would add the modifier code 95 like so: 97803-95.  
• Alphanumeric modifiers use a combination of letters and numbers. One well-known alphanumeric modifier is “-LT” (left side) and “-RT” (right side), used to specify whether a procedure was performed on the left or right side of the body.
• HCPCS (Healthcare Common Procedure Coding System) Level II modifiers aren’t technically CPT modifiers. They may include alphanumeric characters to convey specific information about services, equipment, and supplies. We’ll get into the distinction between CPT and HCPCS a little later in this article. 

Where to Find Current CPT Codes

There are a variety of resources that can help with finding current CPT codes. 

• The American Academy of Professional Coders (AAPC) sells several different CPT books. They also power a platform called Codify that offers a subscription-based look-up tool. 
• The American Medical Association offers links to various coding resources . And they share monthly updates on the CPT code set and related industry news to those who subscribe to their newsletter .
• The Centers for Medicare & Medicaid Services (CMS) offers a free search (CPT code lookup) for RVU (Relative Value Units) for every CPT code. You can also request a CPT/RVU Data File license from the American Medical Association if you want to import codes and descriptions into existing claims and medical billing systems.

The CPT Code Approval Process

The CPT Editorial Panel is composed of 21 members who are responsible for maintaining the CPT code set.

The CPT Editorial Panel is authorized by the American Medical Association Board of Trustees to revise, update, or modify CPT codes, descriptors, rules and guidelines. 

The CPT Editorial Panel meets three times a year and addresses over 200 major topics, each reviewed and discussed with careful consideration.

Criteria for CPT Code Applications

The American Medical Association has set out specific guidelines for adding, deleting, or modifying codes through the CPT Editorial Panel.

There are specific applications to use depending on the nature of the request. The AMA has also outlined the CPT code process in great detail. Here are a few highlights:

• Many different entities can submit applications for changes to CPT codes, including medical specialty societies, individual physicians, hospitals, and third-party payers.
• All requests to revise CPT codes are reviewed by AMA staff. If they believe the CPT Editorial Panel has already addressed a request, they let the requesting party know. If the request represents a new direction then the application is referred to members of the CPT Advisory Committee for consideration and comments.
• After the Advisory Committee consideration, the AMA staff prepare an agenda item that includes the application, compiled CPT Advisor comments and a ballot for decision by the CPT Editorial Panel. Once the CPT Editorial Panel has taken an action and preliminarily approved the minutes of the meeting, AMA staff informs the applicant of the outcome.
• After going through the above process, there are four possible outcomes: a new CPT code is added, a request is referred for further study, consideration is postponed to a future meeting, or the request is rejected. 

CPT Codes vs. HCPCS Codes: Key Differences

The American Medical Association first published CPT codes back in 1966 , when they were mainly used for coding surgical procedures. In 1983, the CMS adopted CPT codes as part of HCPCS. 

The HCPCS code set is divided into two principal subsystems:

• Level I of the HCPCS is the same as the CPT code set. These codes primarily describe medical services and procedures provided by physicians and other healthcare providers in clinical and outpatient settings.
• Level II of the HCPCS is a set of codes distinct from CPT codes. They are used for a broader range of non-physician services and supplies, including durable medical equipment (DME), ambulance services, and certain outpatient procedures. They give providers and payers a standardized language for communication and reimbursement.

Master CPT Codes to Drive Revenue and Elevate Care

Understanding the ins and outs of CPT codes can be a valuable skill for health and wellness practitioners.

Yes, getting CPT codes right the first time ensures you get reimbursed accurately and on time when dealing with insurance of third-party payers. The codes also represent a standardized way to describe and document the specific healthcare services you provide. Keeping comprehensive records supports continuity of care and can be valuable for tracking patient progress over time.

Learn more about the features built into Practice Better to help automate insurance billing – from setting up your insurance billing profile to storing CPT and custom codes into the platform so they are available for use at any time.

Frequently Asked Questions

What are 5 common cpt codes.

The CPT codes that a wellness practitioner uses frequently when billing will depend on the nature of services provided. Here are five Five CPT codes that could be commonly used in a wellness practice. 

CPT code 99401 – Preventive Medicine, Individual Counseling . Wellness professionals might use this code for counseling sessions related to lifestyle modifications, such as nutrition, exercise, or stress management.

CPT code 99078 – Group Health Education. Wellness professionals who conduct group workshops or classes on various health and wellness topics (e.g., diabetic teaching or a prenatal nutrition class for expectant mothers) might use this code to document those educational sessions.

CPT code G0438 – Annual wellness visit (AWV), includes personalized prevention plan of service (PPPS), initial visit. CMS allows for AWV coverage for a medical professional or team under a physician’s supervision, for example registered dietitians or health educators. 

CPT code G0439 – AWV, includes PPPS, subsequent visit. This code is used for AWV visits following the initial one. 

CPT code 97802 – Medical Nutrition Therapy Procedure. A dietitian could use this code for an initial individual, face-to-face assessment and intervention with a client.

How do I look up CPT codes?

The Centers for Medicare & Medicaid Services (CMS) offers a free search (CPT code lookup) for RVU (Relative Value Units) for every CPT code. You can also request a CPT/RVU Data File license from the AMA if you want to import codes and descriptions into existing claims and medical billing systems.

How many CPT codes are there?

According to the AMA, the 2023 CPT code set includes 10,969 codes that describe the medical procedures and services available to patients.

What are CPT 4 codes used for?

CPT 4 is another name for the set of CPT codes published by the AMA for reporting medical procedures and services. It includes the Category I, II, and III CPT codes outlined in the above article.

What is the structure of CPT codes?

CPT codes are five digits and are either numeric or alphanumeric. Each has a descriptor to help users understand their purpose. They are organized into three categories: Category I (most commonly used to report services and procedures), Category II (tracking codes for performance management) and Category III (temporary codes for emerging or experimental activities).

Practice Better is the complete practice management platform for nutritionists, dietitians, and wellness professionals. Streamline your practice and begin your 14-day free trial today.

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• Medicare Annual Wellness Visit

Billing for a Medicare Annual Wellness Visit: Codes G0438 and G0439

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by Lucy Lamboley

The importance of using preventive medicine to improve the health and ultimately lives of patients is widely recognized. The Medicare annual wellness visit (AWV) plays an important role in helping Medicare beneficiaries stay current with their health and take actions that can prevent illness and reduce risk.

An essential piece of the process required to ensure offering and providing preventive services remains financially viable is for organizations to complete the Medicare annual wellness visit reimbursement coding process accurately. Doing so can help ensure providers receive their earned reimbursements and protect them against possible penalties they might incur from failed coding audits. We know some organizations struggle with meeting compliance requirements set forth by the Centers for Medicare & Medicaid Services. 

In this blog post, we take a look at what's required for compliant AWV coding. While this is by no means a comprehensive guide to Medicare annual wellness visit reimbursement, it provides organizations with information that can assist them in avoiding some of the most common AWV coding mistakes that result in rejected claims, lost revenue, or failed audits — all of which can be mitigated when using Prevounce software. 

Three Unique Annual Wellness Visit Codes: G0402, G0438, and G0439

Medicare preventive wellness visits fall into three categories; the "Welcome to Medicare" visit, also known as the  Initial Preventive Physical Exam  (IPPE); the initial annual wellness visit, and the subsequent annual wellness visits. Each has its own Healthcare Common Procedure Coding System (HCPCS) code that must be used in the right circumstances and proper order. 

Understanding HCPCS G0402

During the first 12 months a patient is enrolled in Medicare, they are eligible for the Welcome to Medicare visit or IPPE. This is a one-time visit that includes vital measurements, a vision screening, a depression screening, and other assessments meant to gauge the health and safety of an individual patient. This visit must be coded using HCPCS G0402. Once a patient has been enrolled for more than 12 months, the G0402 code will be rejected regardless of whether the IPPE visit previously took place or not.

Understanding HCPCS G0438

After a patient has been enrolled in Medicare for 12 months, they become eligible for an annual wellness visit. Note: If you need assistance with identifying eligible patients, get this AWV quick guide .

If the Medicare beneficiary had an IPPE completed, the patient is eligible for the initial AWV on the first day of the same calendar month the following year. An AWV is similar to the IPPE but includes slightly different required and accepted screenings. This initial AWV must be coded using HCPCS G0438. 

Understanding HCPCS G0439

HCPCS G0439 is used to code all subsequent Medicare annual wellness visits that occur after the initial AWV (G0438). So, if used correctly, G0439 would not be used until G0402 was used to code the IPPE and G0438 was used to code the initial AWV. In the case that an IPPE was never completed, G0439 would still be used for any subsequent visits after G0438. 

Purpose of Multiple Annual Wellness Visit HCPCS Codes

Though G0402, G0438, and G0439 are commonly confused, the reason for needing three separate codes is pretty straightforward. It is assumed that the different types of visits take different amounts of resources, and so they are reimbursed at different rates.

For example, the initial annual wellness visit is used to collect the library of information that will be continually updated with each subsequent AWV. As a result, the HCPCS G0438 code is reimbursed at a rate that is nearly 50% higher than HCPCS G0439. So if an organization regularly misses using the G0438 code for an initial Medicare AWV and uses G0439 instead, it could mean numerous denials and a significant loss of revenue. 

Additional AWV HCPCS and CPT Codes

In addition to the primary annual wellness visit codes (G0402, G0438, and G0439), a select list of other codes may be billed for services performed during a Welcome to Medicare visit or AWV. When using any of these codes, a separate note is required to support each rendered service. 

It is important to understand that many of these codes have specific guidelines that require them only to be used with specific visits after meeting certain criteria. For example, HCPCS G0444, which designates a 15-minute annual depression screening, may only be included with subsequent wellness visits billed under G0439. If that specific code is used with the IPPE or initial AWV, it will be rejected as invalid. An abdominal aortic aneurysm (AAA) screening, coded as G0389, may only be performed with the IPPE code G0402. It is not approved for annual wellness visits. 

Advance care planning (CPT 99497) is considered an optional element of the annual wellness visit, which includes a discussion with the patient about their advance care wishes and advance directive. Advance care planning, also referred to as ACP, is considered a preventive service (and thus has its co-pay waived) when billed on the same day as an AWV with modifier -33.

HCPCS G0442 and HCPCS G0443 are additional codes that must be used in conjunction with each other to be valid. G0442 is used for an annual alcohol screening, which should take approximately 15 minutes. G0443 is for 15-minute sessions of alcohol counseling.  According to the Centers for Medicare & Medicaid Services (CMS), the screening service must take place before a counseling service is approved. In other words, if G0443 is used and there are no claims for G0442 in the preceding 12 months, the screening code will be denied. 

Fifteen-minute  obesity counseling  sessions may be billed in conjunction with IPPE visits or annual wellness visits using HCPCS G0447. This service includes dietary assessments and behavioral counseling, but a patient must have a body mass index of thirty or above to qualify.

If you ever have a wellness visit that takes a particularly long time, there is also a set of add-on codes you can use. HCPCS G0513 and HCPCS G0514 are "prolonged preventive service codes" that can be used when a service takes 30 minutes (G0513) or 60-plus minutes (G0514) past the typical duration of the service.

Staying Current With Annual Wellness Visit Coding Requirements 

To avoid risking an audit, it is essential to stay up to date on coding requirements associated with Medicare annual wellness visits as they undergo occasional revisions. For example, in the 2023 Physician Fee Schedule (PFS) final rule , two preventive services had their HCPCS code descriptors modified. HCPCS G0442 was changed to "Annual alcohol misuse screening, 5 to 15 minutes" and HCPCS G0444 was changed to "Annual depression screening, 5 to 15 minutes." The codes currently require a minimum of 15 minutes of services. Such coding revisions and sometimes replacement is relatively common, and utilizing incorrect codes will lead to denied claims.

With changing guidelines and eligibility requirements, the task of coding correctly to better ensure proper reimbursement on preventive health visits can prove challenging for business office staff. But without the necessary revenue, organizations may struggle to support the delivery of preventive health services, which could negatively impact the care given to patients. 

Providing the Annual Wellness Visits and Preventive Care in a Financially Sustainable Way

Medicare annual wellness visits and associated preventive services are not just valuable for patients. Organizations that provide these services can increase their revenue opportunities. In fact, by expanding establishing or growing an AWV program, an organization can generate significant, recurring reimbursement, as is covered in this on-demand webinar .

But Medicare hasn't made it easy for organizations to maintain compliance with its various AWV coding, billing, documentation, and service requirements, as rules undergo regular changes that can easily be missed or misunderstood. Enter Prevounce.

Prevounce lifts the burden of sorting through Medicare regulations to help you understand how preventive services can be utilized to best benefit the patient and your organization. Our platform improves everything from AWV eligibility verification to patient outreach and intake, to billing and coding, to completion of documentation, and more. To learn what Prevounce can do for your AWV program, whether it's in its infancy or ready for significant growth, schedule a demo today ! 

CPT Copyright 2023 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Health economic and reimbursement information provided by Prevounce is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules, and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Prevounce encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services rendered. It is also always the provider’s responsibility to understand and comply with Medicare national coverage determinations (NCD), Medicare local coverage determinations (LCD), and any other coverage requirements established by relevant payers which can be updated frequently. Prevounce recommends that you consult with your payers, reimbursement specialists, and/or legal counsel regarding coding, coverage, and reimbursement matters. Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements. The coding options listed here are commonly used codes and are not intended to be an all- inclusive list. We recommend consulting your relevant manuals for appropriate coding options. The Health Care Provider (HCP) is solely responsible for selecting the site of service and treatment modalities appropriate for the patient based on medically appropriate needs of that patient and the independent medical judgement of the HCP.

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Prevounce creates wellness that works for everyone, with practice-specific, software-based programs that make preventive care, chronic care management, and remote patient monitoring easier to prep for, perform, document, and bill.

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Welcome to our comprehensive guide on Annual Wellness Visit CPT codes. Medicare started providing coverage for Annual Wellness Visits on January 1, 2011, as part of the Affordable Care Act of 2010. These visits are aimed at promoting preventive care and developing personalized prevention plans for patients. Understanding the specific codes and guidelines for billing and documentation is crucial to ensure proper reimbursement and compliance.

During an Annual Wellness Visit, healthcare professionals assess the medical and family history of patients, measure height, weight, and blood pressure, review risk factors, and provide counseling services. These visits are divided into two categories: the initial visit (G0438) and subsequent visits (G0439). The initial visit is performed on patients who have been enrolled with Medicare for more than one year, while subsequent visits can be done one year after the initial visit.

To properly bill for Annual Wellness Visits, it is important to use the correct CPT code, document all necessary elements, and adhere to billing and reimbursement guidelines. In this guide, we will provide you with the information you need to navigate Annual Wellness Visit CPT codes and ensure accurate coding, billing, and reimbursement.

Key Takeaways:

• Medicare provides coverage for Annual Wellness Visits as part of preventive care services.
• Annual Wellness Visits are divided into initial visits (G0438) and subsequent visits (G0439).
• Proper documentation is crucial for billing and reimbursement.
• Medical professionals should use the appropriate CPT code for billing.
• Staying updated on changes in CPT codes and compliance regulations is essential.

Understanding the Annual Wellness Visit CPT Codes

The Annual Wellness Visit CPT Codes (G0438 and G0439) provide coverage for a wide range of services that aim to promote preventive care and develop personalized prevention plans for patients. These codes encompass various assessments and evaluations to ensure comprehensive care and early detection of potential health issues. Let’s delve into the details of these codes and understand how they contribute to the well-being of patients.

Annual Wellness Visit Guidelines

To fully benefit from the Annual Wellness Visit CPT Codes, it is essential to adhere to specific guidelines. These guidelines ensure that healthcare professionals thoroughly assess patients’ medical and family history and perform measurements such as height, weight, and blood pressure. In addition, they include cognitive impairment detection, review of risk factors, establishment of a screening schedule, and provision of advice and referrals for health education and counseling services. By following these guidelines, healthcare providers can deliver comprehensive preventive care tailored to each patient’s individual needs.

Annual Wellness Visit Reimbursement

Medicare provides reimbursement for Annual Wellness Visits. However, it is essential to follow the specific documentation requirements to ensure proper reimbursement. Healthcare professionals should use standardized templates to accurately capture all necessary elements during the visit, such as medical and family history, current providers, measurements, risk assessments, screening schedules, and counseling services. Detailed and accurate documentation supports the medical necessity of the visit and ensures smooth reimbursement. By following the guidelines and proper documentation practices, healthcare providers can ensure that their services are reimbursed appropriately.

Documentation and Billing for Annual Wellness Visits

Proper documentation is essential for the successful billing and reimbursement of Annual Wellness Visits. To ensure accurate and complete documentation, healthcare professionals should utilize a standardized template that captures all the necessary elements. This template should include:

• Medical and family history
• Current providers
• Measurements (e.g., height, weight, blood pressure)
• Risk assessments
• Screening schedules
• Counseling services

The documentation should be detailed and precise, supporting the medical necessity of the visit and providing a comprehensive overview of the patient’s health status. By using a structured template, healthcare professionals can ensure consistency and completeness in capturing the required information.

Furthermore, billing for Annual Wellness Visits should be done using the appropriate CPT code. The initial visit is billed under CPT code G0438, while subsequent visits are billed under CPT code G0439.

By adhering to proper documentation and billing practices, healthcare professionals can effectively manage the billing and reimbursement process for Annual Wellness Visits and optimize patient care.

Medicare and Preventive Care CPT Codes

In addition to the Annual Wellness Visit CPT Codes, Medicare also covers a range of preventive care services through specific CPT codes. These services are designed to promote overall wellness, prevent illness, and detect conditions at an early stage. Medicare covers various preventive care procedures, including screenings, vaccinations, counseling, and behavioral interventions.

Here are some examples of preventive care CPT codes:

• 99387 – Complete Physical Exam for patients aged 65 and older
• 99397 – Complete Physical Exam for patients aged 65 and older (subsequent visit)
• G0101 – Well Woman Exam
• Q0091 – Screening Pap Smear

These codes represent a small portion of the available preventive care CPT codes. Healthcare professionals should review the complete list of preventive care CPT codes provided by Medicare to ensure they are providing all necessary preventive care services to their patients.

When billing for preventive care services, it is important to use the appropriate CPT codes to ensure accurate reimbursement. By following the annual wellness visit checklist and using the correct preventive care CPT codes, healthcare professionals can provide comprehensive preventive care to their patients while maximizing reimbursement.

Understanding CPT Codes and Their Structure

CPT codes, or Current Procedural Terminology codes, play a crucial role in the healthcare industry. They serve as a standardized set of codes used to describe various medical, surgical, and diagnostic services provided to patients. Maintained by the American Medical Association (AMA), CPT codes are essential for effective billing, reimbursement, and documentation processes.

A CPT code comprises three key components:

• Numeric Code: This code uniquely identifies a specific procedure or service. It helps in accurately categorizing healthcare services and treatments.
• Modifiers: These optional two-digit codes provide additional information about a procedure or service. Modifiers help to indicate, clarify, or modify certain aspects of the service, such as the extent or circumstances of the procedure.
• Description: The description accompanying the code explains the nature of the procedure or service. It provides essential details about the medical intervention, enabling healthcare professionals to accurately understand and communicate the care provided.

CPT codes and ICD-10 codes, which are used for describing diagnoses and conditions, are distinct and serve different purposes. While ICD-10 codes focus on identifying and classifying diagnoses, CPT codes concentrate on procedures and services rendered during patient care.

Understanding the structure and components of CPT codes is essential for accurate coding and effective communication within the healthcare industry. These codes enable clear documentation, facilitate streamlined billing processes, and ensure appropriate reimbursement for the services provided.

Categories of CPT Codes

CPT codes are an essential component of medical coding, used to describe the various procedures, tests, and treatments provided to patients. These codes are categorized into three main categories: Category I CPT codes, Category II CPT codes, and Category III CPT codes.

Category I CPT codes

Category I codes are the most commonly used CPT codes and cover a wide range of medical procedures, tests, and treatments. These codes are established and regularly updated by the American Medical Association (AMA). Healthcare professionals use Category I codes to accurately document and bill for the services they provide. They are the foundation of the CPT code set and play a vital role in healthcare reimbursement.

Category II CPT codes

Category II codes are supplementary codes used for performance measurement and quality reporting. Unlike Category I codes, Category II codes are not used for billing purposes. Instead, they are used to collect data on the quality of healthcare services provided. These codes help in tracking and evaluating the effectiveness of interventions, treatments, and preventive measures. Healthcare professionals can use Category II codes to report additional information that may be useful in assessing the quality of care.

Category III CPT codes

Category III codes are temporary codes used for emerging technologies and services that do not yet have established Category I codes. These codes are often used for new procedures, treatments, or technologies that are still in the early stages of adoption. Category III codes allow healthcare professionals to track and report the usage and outcomes of these emerging services. As medical advancements continue, some Category III codes may eventually transition to Category I codes when they become widely accepted and established.

Here is a visual representation of the categories of CPT codes:

Healthcare professionals should be familiar with these categories and ensure they use the appropriate codes for their services. Accurate coding is essential for proper documentation, billing, and reimbursement, ultimately facilitating the delivery of quality healthcare.

Finding and Using CPT Codes

When it comes to finding and using CPT codes, there are several resources available to ensure accurate and up-to-date coding. Whether you need to look up a specific CPT code or stay informed about the latest updates in coding guidelines, these resources can be invaluable.

One well-known resource for CPT codes is the American Academy of Professional Coders (AAPC). They offer comprehensive CPT books that provide detailed descriptions and explanations of each code. Additionally, AAPC offers a subscription-based lookup tool called Codify, which allows users to quickly search for specific CPT codes and access coding guidance.

The American Medical Association (AMA) is another reputable organization that provides coding resources. They offer links to various coding resources on their website, including updates on CPT codes. These monthly updates keep healthcare professionals informed about any changes or additions to the CPT code set.

The Centers for Medicare & Medicaid Services (CMS) also offer valuable resources for CPT code lookup. Their free CPT code lookup tool allows users to search for specific codes and provides additional information about each code. CMS also provides a CPT/RVU Data File license, which allows healthcare professionals to import CPT codes into their billing systems.

Staying current with the latest CPT codes and updates is crucial for accurate coding and billing. By utilizing these resources, healthcare professionals can ensure that they are using the appropriate codes and providing the best possible care to their patients.

Benefits of Using CPT Code Resources:

• Access to comprehensive CPT books and lookup tools for quick code searches
• Regular updates on coding guidelines and changes to the CPT code set
• Additional coding resources and guidance for accurate billing and documentation
• Free tools and licenses provided by CMS for easy code lookup and integration into billing systems
• Improved coding accuracy and reimbursement rates

Responsibilities of the CPT Editorial Panel

The CPT Editorial Panel plays a vital role in the ongoing development and maintenance of CPT codes. Composed of 21 members, the panel is responsible for revising, updating, and modifying the Current Procedural Terminology (CPT) code set.

Meeting regularly, the CPT Editorial Panel addresses over 200 topics related to codes, descriptors, rules, and guidelines. Their work ensures that the CPT codes accurately reflect contemporary medical practices and services.

Authorized by the American Medical Association (AMA), the CPT Editorial Panel is dedicated to maintaining the accuracy and relevance of the CPT code set. This commitment ensures healthcare professionals have access to standardized codes that facilitate proper billing, documentation, and reimbursement.

For healthcare professionals, it is crucial to stay updated on any changes or modifications to the CPT codes. Understanding the work done by the CPT Editorial Panel helps us provide accurate coding and billing services, ensuring compliance with industry standards and maximizing reimbursement for the services we provide.

Let’s take a look at an overview of the CPT Editorial Panel’s responsibilities:

The CPT Editorial Panel’s dedication to ongoing improvement ensures that healthcare professionals have access to up-to-date and reliable coding resources, supporting the highest quality of care for patients.

Coding Guidelines and Compliance for Medical Professionals

Medical coding is a vital profession that requires formal education, training, and certification. As medical coders, we have the responsibility to accurately assign codes to healthcare services and procedures. It is crucial for us to stay up to date with evolving healthcare regulations, payer policies, and compliance requirements to ensure accurate and compliant coding practices.

Coding errors can have significant financial implications, leading to underpayment, delayed payments, or even non-payment by insurance companies. To avoid these issues, it is imperative that we strictly adhere to medical coding regulations and guidelines.

One of the key regulations we must comply with is the Health Insurance Portability and Accountability Act (HIPAA), which protects patient privacy and ensures the security of medical information. We must always handle patient data in a confidential and secure manner, following HIPAA guidelines.

Additionally, being prepared for coding audits is essential. Insurance companies, government agencies, and other entities may conduct audits to verify the accuracy and compliance of our coding practices. By maintaining thorough documentation and demonstrating compliant coding, we can navigate these audits successfully.

Key Points to Ensure Coding Compliance:

• Stay up to date with coding guidelines from organizations such as the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS).
• Thoroughly review and understand payer policies and requirements to align coding practices accordingly.
• Use accurate and specific codes that best represent the healthcare services provided.
• Document the medical necessity of each procedure or service performed to support proper coding.
• Ensure proper documentation of any additional services or procedures performed concurrently.
• Regularly review and update coding documentation templates to reflect changes in coding regulations and requirements.

In summary, as medical coders, it is our responsibility to adhere to coding guidelines, comply with regulations like HIPAA, and be prepared for coding audits. By prioritizing compliance and accuracy in our coding practices, we can contribute to the overall integrity of healthcare systems and ensure proper reimbursement for the services provided.

Updates and Changes in CPT Codes

CPT codes undergo annual updates to ensure accuracy and relevance in the ever-evolving healthcare landscape. These updates involve the addition of new codes, revision or deletion of existing codes, and the introduction of modifiers.

Staying current with these updates is crucial for accurate coding and billing processes. By keeping up-to-date with the latest changes, healthcare professionals can ensure proper documentation and maximize reimbursement.

Importance of CPT Code Updates

The updates in CPT codes reflect advancements in medical procedures, technologies, and medical practices. They enable accurate reporting of services and facilitate efficient communication among healthcare providers, payers, and regulatory entities.

It is essential for healthcare professionals to stay informed about the updates to ensure compliance with the latest coding standards and guidelines. Failing to use the most updated codes may lead to claim denials or incorrect billing, which can negatively impact revenue and patient care.

Modifiers in CPT Codes

In addition to code changes, modifiers are introduced to provide additional information about the service or procedure performed. Modifiers help convey important details that can affect the reimbursement and understanding of the healthcare service.

For example, modifiers can indicate the side of the body on which a procedure is performed or whether multiple procedures were performed during a single encounter. These modifiers play a crucial role in accurately documenting and billing for healthcare services.

It is important for healthcare professionals to be familiar with the available modifiers and understand when and how to apply them correctly. Proper use of modifiers ensures clarity, accuracy, and appropriate reimbursement.

Benefits of Using Updated CPT Codes and Modifiers

Using the most updated CPT codes and modifiers provides several benefits for healthcare professionals:

• Accurate billing and reimbursement: Updated codes and modifiers ensure that the services provided are properly documented and categorized, leading to accurate billing and appropriate reimbursement.
• Compliance with regulations: Using outdated codes or failing to apply the appropriate modifiers may result in non-compliance with coding regulations, potentially leading to audits, penalties, or legal issues.
• Improved communication and coordination: Updated codes and modifiers facilitate effective communication and coordination among healthcare providers, payers, and regulatory entities, ensuring seamless information exchange.
• Enhanced patient care: Accurate coding allows healthcare professionals to provide comprehensive and appropriate care to patients, improving patient outcomes and satisfaction.

By prioritizing the use of updated CPT codes and understanding the purpose and application of modifiers, healthcare professionals can streamline coding and billing processes, optimize reimbursement, and deliver high-quality care.

Skilled Therapy Services and Coverage Guidelines

When it comes to skilled therapy services, including physical therapy and occupational therapy, Medicare provides coverage for these services if they are deemed reasonable and necessary for the diagnosis, treatment, or improvement of a patient’s condition. The coverage is not dependent on the patient’s potential for improvement but rather on the need for skilled care.

Maintenance programs, aimed at maintaining or slowing the deterioration of a patient’s functional status, are also covered if provided by a qualified therapist. This means that even if the patient’s condition may not improve, Medicare still covers therapy services as long as they are essential for the patient’s ongoing care and functional well-being.

It is important for healthcare professionals to properly document the necessity and effectiveness of skilled therapy services to ensure reimbursement. Adherence to coverage guidelines is crucial for successful reimbursement claims.

Skilled Therapy Coverage Guidelines

Medicare has specific guidelines in place for the coverage of skilled therapy services. These guidelines ensure that therapy services are provided according to medical necessity and meet certain criteria. Healthcare professionals should be familiar with and follow these guidelines to ensure proper reimbursement and patient care.

Some of the coverage guidelines for skilled therapy services include:

• The therapy services must be provided by a qualified therapist, such as a licensed physical therapist or occupational therapist.
• The services should be aimed at improving, maintaining, or slowing the deterioration of the patient’s functional status.
• The therapy services should be directly related to the patient’s diagnosis and treatment plan.
• The therapy services should be reasonable and necessary for the patient’s condition, taking into account the specific needs and goals of the patient.
• Proper documentation should be maintained, including progress notes, treatment plans, and outcome measures, to demonstrate the medical necessity of the therapy services.

By following these coverage guidelines, healthcare professionals can ensure that their patients receive the necessary skilled therapy services and that they are properly reimbursed for their services.

Therapy Students and Coverage Guidelines

Therapy students play a valuable role in the care of patients under the direct supervision of qualified professionals, such as licensed therapists. However, it’s important to note that services provided by students are not reimbursed. To ensure proper reimbursement, a qualified professional must be present in the room, directly supervise the service, and sign all documentation.

Understanding the guidelines and requirements for involving therapy students in the care process is paramount for healthcare professionals. By adhering to these guidelines, we can ensure that students gain valuable hands-on experience while maintaining the integrity of reimbursement for the services provided.

Therapy Student Involvement Guidelines

When involving therapy students in patient care, it is crucial to follow these guidelines:

• The therapy student must be under the direct supervision of a qualified professional at all times.
• The qualified professional must be present in the room during the service and actively supervise the student.
• The qualified professional must assume responsibility for the overall management and direction of the patient’s therapy, ensuring the student’s work aligns with the patient’s treatment plan.
• All documentation, including progress notes and any required forms, must be co-signed by the qualified professional to verify their presence and supervision during the service.

Adhering to these guidelines not only ensures compliance with coverage requirements but also allows us to provide a valuable learning experience for therapy students while upholding the highest standard of care for our patients.

Example: Therapy Student Involvement

To illustrate how therapy student involvement works in practice, let’s consider an example:

In this example, therapy student Sarah Williams, under the direct supervision of qualified professional Emily Thompson, PT, assists in the post-surgical knee rehabilitation of patient John Smith. Both therapists co-sign all necessary documentation to ensure compliance with coverage guidelines.

By understanding and adhering to the therapy student involvement guidelines, we can contribute to the education and training of future therapists while providing exceptional care to our patients.

Resources for Coding and Billing

In the world of healthcare coding and billing, it is crucial for professionals to have access to reliable resources. Whether you’re a therapist looking for billing scenarios or a coding specialist in need of guidance, there are several valuable resources available to assist you in your work.

Centers for Medicare & Medicaid Services (CMS)

The CMS is a leading authority when it comes to Medicare coding and billing. They offer a range of publications that provide detailed guidance on coding and billing requirements. Two notable resources from CMS are the Medicare Benefit Policy Manual and the Claims Processing Manual. These publications serve as comprehensive references for healthcare professionals, offering insights into the intricacies of coding and billing for Medicare services.

In addition to publications, the CMS website also offers billing scenarios specifically designed for therapists. These scenarios can help therapists navigate challenging situations and ensure accurate billing for their services.

American Academy of Professional Coders (AAPC)

As a well-established professional organization, the AAPC offers a wealth of coding resources and updates. They provide coding books for various medical specialties, including therapy services, which can serve as a valuable reference in your day-to-day coding work.

American Medical Association (AMA)

The AMA is another reputable organization that provides coding resources and updates. They offer links to coding resources on their website, keeping healthcare professionals up to date with the latest coding trends and developments.

It is important to leverage these resources and stay informed about coding and billing guidelines, as they ensure accurate reimbursement for your services. With the right guidance, you can confidently navigate the complex world of coding and billing, ensuring compliance and maximizing revenue.

The Annual Wellness Visit CPT Code Guide provides a comprehensive overview of the coding and billing requirements for annual wellness visits. By understanding the guidelines, documentation requirements, and coverage guidelines, healthcare professionals can optimize reimbursement and provide quality preventive care to their patients.

Staying updated on changes in CPT codes and compliance regulations is crucial for accurate coding and billing. It is important to use the appropriate codes and modifiers, follow proper documentation practices, and stay informed about any updates or revisions in the codes.

By following the guidelines outlined in the Annual Wellness Visit CPT Code Guide, healthcare professionals can ensure the best possible care for their patients, promote preventive care, and contribute to overall patient well-being. The guide serves as a valuable resource for healthcare professionals navigating the complexities of annual wellness visit coding and billing.

What are the Annual Wellness Visit CPT Codes?

The Annual Wellness Visit CPT Codes are G0438 (Initial Visit) and G0439 (Subsequent Visit). These codes are used to bill for preventive care services and the development of personalized prevention plans for patients.

What services are included in the Annual Wellness Visit?

The Annual Wellness Visit includes medical and family history assessment, measurements of height, weight, and blood pressure, detection of cognitive impairment, review of risk factors, establishment of a screening schedule, and provision of advice and referrals for health education and counseling services.

How should the Annual Wellness Visit be documented?

Healthcare professionals should use a standardized template to document the Annual Wellness Visit. The documentation should include medical and family history, current providers, measurements, risk assessments, screening schedules, and counseling services.

What other preventive care services are covered by Medicare?

Medicare also covers other preventive care services through specific CPT codes. These services include screenings, vaccinations, counseling, and behavioral interventions to prevent illness or detect conditions at an early stage.

What is the purpose of CPT codes?

CPT codes are a standardized set of codes used to describe medical, surgical, and diagnostic services. They are essential for billing, reimbursement, and documentation.

What are the different categories of CPT codes?

CPT codes are divided into three main categories: Category I codes, Category II codes, and Category III codes. Category I codes describe a wide range of medical procedures, Category II codes are supplementary codes used for performance measurement, and Category III codes are temporary codes for emerging technologies and services.

Where can I find current and updated CPT codes?

Current and updated CPT codes can be found in resources such as CPT books, online lookup tools, and coding resources provided by organizations like the American Academy of Professional Coders (AAPC) and the American Medical Association.

Who is responsible for maintaining the CPT code set?

The CPT Editorial Panel, authorized by the American Medical Association, is responsible for maintaining the CPT code set and ensuring its accuracy and relevance.

What are the responsibilities of medical coders?

Medical coders are responsible for accurately assigning codes to healthcare services and procedures and staying up to date with healthcare regulations, payer policies, and compliance requirements.

How are CPT codes updated?

CPT codes are updated annually, with new codes being added, existing codes being revised or deleted, and modifiers being introduced. Healthcare professionals should stay current with these changes to ensure accurate coding and billing.

What are the coverage guidelines for skilled therapy services?

Skilled therapy services, including physical therapy and occupational therapy, are covered by Medicare when they are reasonable and necessary for the diagnosis, treatment, or improvement of a patient’s condition.

Can therapy students participate in the care of patients?

Therapy students can participate in patient care under the direct supervision of a qualified professional, but their services are not reimbursed.

What resources are available for coding and billing?

Resources for coding and billing include publications from the Centers for Medicare & Medicaid Services, coding resources provided by professional organizations, and online tools for looking up CPT codes.

Where can I find a comprehensive Annual Wellness Visit CPT Code Guide?

You can find a comprehensive Annual Wellness Visit CPT Code Guide in this master guide, which provides an overview of coding and billing requirements as well as guidelines for Annual Wellness Visits.

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Annual Wellness Visit | CPT codes

2024 CPT Codes for Annual Wellness Visits

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January 4th, 2024 | 9 min. read

ThoroughCare

Content Team

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An Annual Wellness Visit (AWV) is a preventive screening used to identify gaps in care. 

As covered by Medicare Part B, providers should understand what CPT billing codes matter to the service and how to use them. This can help your organization avoid denied claims and enhance care. 

AWVs are covered for Medicare Part B patients without a co-pay. This yearly assessment helps patients create personalized care plans that providers can use to improve outcomes. 

AWVs are reimbursable under Medicare’s Physician Fee Schedule, paying various rates. 

AWV CPT Codes to Know: G0402, G0438, G0439

Different CPT billing codes reflect specific types of Medicare wellness visits. The crucial qualifying determinant is when a certain AWV can be provided and billed for.

There are three types of wellness visits : Initial Preventive Physical Examination (IPPE), an Initial Annual Wellness Visit, and the Subsequent Annual Wellness Visit. Each entails a different billing code as well as specific qualifiers for each program.

• Initial Preventive Physical Examination (G0402) : Patients may only receive this benefit within the first 12 months of their Medicare enrollment. Commonly referred to as the “welcome to Medicare visit,” it is considered a once in a lifetime assessment and after the initial eligibility period, the patient cannot receive an Initial Preventive Physical Examination. It is also dependent on the health risk assessment .
• Initial Annual Wellness Visits (G0438) : Similar to an Initial Preventive Physical Examination, except it is available to a patient after 11 months of Medicare enrollment. This is for patients that miss their window for an Initial Preventive Physical Examination. However, if the patient does complete an Initial Preventive Physical Examination, they must still complete the Initial Annual Wellness Visit. This screening also includes an optional cognitive exam and end-of-life planning. 
• Subsequent Annual Wellness Visit (G0439) : Is the yearly follow-up to an Initial Annual Wellness Visit. Eleven full months after the Initial Annual Wellness Visit, a patient can attend these visits to modify and maintain their preventive care plan, based on how their health is at any given time.

About AWVs and Their Billing Requirements

Medicare’s wellness visit is a yearly assessment of a patient’s health used to identify risks and create a personalized care plan. AWVs are different from yearly physical examinations. They offer a more complete review of a patient’s medical history and current lifestyle to suggest care goals that close gaps . 

Wellness visits can be of particular importance for patients living with chronic conditions. 

With an AWV, a personalized care plan is designed to help manage chronic illnesses , as well as schedule preventive screenings to improve early detection of disease. 

Who Can Provide AWVs?

AWV billing must be directed by a provider with an NPI number. However, clinical staff can administer most of the assessment, saving physician time and involvement. Eligible providers include: 

• Physician assistants
• Nurse practitioners
• Certified nurse midwives
• Clinical nurse specialists
• Pharmacists

AWV Billing Requirements

The following components must be included in a patient’s wellness visit:

• A health risk assessment
• A review and update of medical and family history
• A review of current providers, prescriptions/medications, and durable medical equipment suppliers
• Height, weight, blood pressure, BMI, and other routine measurements
• Personalized health advice, health education, and preventative counseling
• A list of identified risk factors, current medical and mental health conditions, and recommended treatment options
• A cognitive impairment screening
• A five to 10-year screening schedule for appropriate preventive services
• A review of the patient’s functional ability and level of safety, including screening for hearing impairments, risk of falling, activities of daily living, and level of home safety
• Identification of patients at risk for alcohol, tobacco, and opioid abuse
• Advance care planning

Submitting Claims to Medicare

Five items are required when submitting a Medicare claim :

• A CPT Code for the specific type of AWV provided
• An ICD-10 code for a general adult medical examination (Z00.00)
• Date of service
• Place of service (most office in-office or telehealth)
• Submit NPI number

It is helpful to know the staff care coordinator assigned to a patient in case of an audit.

Three Steps to Bill for AWVs:

• Verify CMS requirements were met
• Submit claims to CMS annually (or when best for your organization)
• Determine there are no conflicting billing codes

Additional AWV Billing Opportunities 

Medicare supports additional CPT codes for optional, add-on services related to AWVs. These include Advance Care Planning and a social determinants of health screening. 

Advance Care Planning with AWVs

Advance Care Planning helps patients prepare for future medical decision-making in case of serious illness or they are unable to communicate their care preferences. Specifically, Advance Care Planning includes two primary documents: 

• A living will
• A durable healthcare power of attorney

An AWV assessment asks patients whether they have Advance Care Planning documents in place. If not, the provider can use the AWV to discuss advance care options and schedule time to complete a plan. 

CPT Code 99497

The average billing rate is $80.56. To accurately bill for code 99497, services must:

• Allow for 30 minutes of a face-to-face consultation with the patient, their family member(s), and/or a surrogate (with a minimum of 16 minutes of service time documented)
• Be provided by a physician or other qualified healthcare professional
• Include an explanation and review of advance care directives and options for completing them

Documentation to account for at least 16 minutes of service time should record that the ACP conversation was voluntary on behalf of the patient, encapsulate what was talked about, record who was present for the conversation, and note the length of time for the consultation. 

Again, it is not required to complete an advance care directive during ACP. Completion is only required if you’ve noted in your documentation that you’ve performed this task. However, when ACP is completed with an AWV, it is entirely covered for the patient . 

CPT Code 99498

This is simply an add-on billing code to allow for an additional 30 minutes of ACP services. The average reimbursement rate is $69.75. Requirements for billing this code include:

• Listing this billing claim separately in addition to the code for the primary consultation
• That a minimum of 16 minutes past the first 30 minutes is documented using the same documentation requirements noted above. 

Social Determinants of Health Assessment with AWVs

Providers can collect social determinants of health ( SDOH ) data while performing an AWV. SDOH discussions should be between 5 and 15 minutes in length, and cover food and housing insecurities, transportation needs, and utility difficulties. 

The SDOH risk assessment addresses factors that influence the diagnosis and treatment of patients’ medical conditions. While not designed as a screening, the assessment is tied to one or more known or suspected SDOH needs. 

CPT Code G0136

Providers can receive an additional $18.66 for assessing SDOH during an AWV. For the patient, this assessment is fully covered by Medicare when provided with an AWV. 

To claim this CPT code, providers must:

• Deliver 5-15 minutes of SDOH discussion
• Not assess a patient more than every 6 months
• Administer a standardized, evidence-based SDOH risk assessment

Medicare stresses the importance of following up with patients about SDOH and working to connect them with available resources. 

AWVs for Federally Qualified Health Centers

Federally Qualified Health Centers (FQHC) can bill for AWVs, but they utilize additional codes.

In addition to the standard CPT codes associated with AWVs, an FQHC may use a special add-on code (G0468) that will support additional reimbursement. 

For example, if an FQHC were to provide an Initial Preventive Physical Examination, the clinic would bill for G0402 + G0468. This coding indicates to Medicare that the service is being provided through an FQHC. 

These organizations receive much higher average reimbursement rates.

AWVs Promote Value-based Care

AWVs ask about lifestyle, social history, mental health and home environment. Documenting these details can help providers risk-stratify patient populations and develop comprehensive, personalized care plans that can close gaps. 

This can help clinicians better coordinate services, streamline collaborative decision-making and support value-based care delivery. AWVs have been shown to build stronger provider-patient relationships, secure additional revenue and contribute to cost savings.

ThoroughCare Simplifies Annual Wellness Visits

ThoroughCare offers end-to-end workflow for Annual Wellness Visits.

We simplify the process, so providers can focus on engaging patients. Guided interviews help ask the right questions and ensure all service requirements are met. ThoroughCare includes digital solutions, such as:

• An interactive health risk assessment
• Screening tools, such as ADL, CAGE, DAST-10, GAD-7, MDQ, PAC, PHQ-2, and a mini cognitive exam
• A care gaps summary with recommended interventions
• A full report of Personalized Prevention Plan Services
• Comprehensive care planning tools
• Automated CPT code assignment for accurate billing

*Reimbursement rates are based on a national average and may vary depending on your location.

Check the Physician Fee Schedule for the latest information.

CPT CODE 99391, 99395, 99396, 99397, 99394 – Preventive Exam

Sep 12, 2016 | Medical billing basics

CPT CODE AND Description

99391 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) – Average fee amount $90

99392 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years)  Average fee amount $105 99393 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) Average fee amount $110

99394 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Average fee amount $120

99395 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years 99396 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years 99397 – Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older

Referral/notification/preauthorization requirements

There are no referral/preauthorization requirements for well baby/well child care visits when provided by a contracted FCHP primary care physician within the member’s product network.

Billing/coding guidelines

For new patients making a well baby/well child care visit:

• For infants under age 1, use CPT code 99381.

• For children ages 1 to 4 (early childhood), use CPT code 99382.

• For children ages 5 to 11 (late childhood), use CPT code 99383.

• For children ages 12 to 17 (adolescent), use CPT code 99384.

• For children age 18 (adolescent), use CPT code 99385.

For established patients making a well baby/well child care visits:

• For infants under age 1, use CPT code 99391.

• For children ages 1 to 4 (early childhood), use CPT code 99392.

• For children ages 5 to 11 (late childhood), use CPT code 99393.

• For children ages 12 to 17 (adolescent), use CPT code 99394.

• For children age 18 (adolescent), use CPT code 99395.

Preventive Medicine Visits • Not all insurers pay for preventive medicine visits. For example, these visits are not covered by Medicare.

If you suspect a patient does not have coverage, advise him or her of your billing policies.

• Insurers that do cover preventive medicine visits (eg, many HMOs) generally reimburse them at relatively high rates.

• Regardless of whether a preventive medicine visit is covered, the relevant codes can be used alone or in conjunction with a code for an E&M service (see below).

Patient and Visit Preventive Medicine Code

New patient, initial visit Age 40 through 64 years 99386 Age 65 years and older 99387 Established patient, periodic visit Age 40 through 64 years 99396 Age 65 years and older 99397

Preventive Medicine Services: Established Patients

Periodic comprehensive preventive medicine reevaluation and management of an individual includes an age- and gender-appropriate history; physical examination; counseling, anticipatory guidance, or risk factor reduction interventions; and the ordering of laboratory or diagnostic procedures. CPT Codes                        ICD-9-CM Codes

99391 Infant (younger than 1 year)           V20.31 Health supervision for newborn under 8 days old

                                             V20.32 Health supervision for newborns 8 to 28 days old

                                             V20.2 Routine infant or child health check

99392 Early childhood (age 1–4 years)        V20.2 Routine infant or child health check

99393 Late childhood (age 5–11 years)        V20.2 Routine infant or child health check

99394 Adolescent (age 12–17 years)           V20.2 Routine infant or child health check

99395 18 years or older                V70.0 Routine general medical examination  at a health care facility

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402 are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a pre  existing problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse the Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.existing problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse the Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will  not be reimbursed.

Policy Statement

Preventive medicine services are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from diseaserelated diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the preventive visit, and significant elements of related E/M services are provided during the same visit. When this occurs, Medica will reimburse the preventive medicine E/M service at the contracted rate and the problem-oriented E/M service at 75% of the contracted rate, when appended with modifier 25.

Procedure codes used to bill preventive medicine services are:

** Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397

During a visit for a preventive medicine service, other services may be provided.

HealthWatch EPSDT codes PLUS Evaluation & Management (E&M) Codes PLUS Modifier 25* 

PLUS ICD-9 Diagnosis Codes 99381–99385or 99391–99395

The components of the EPSDT visit must be provided and documented.

99203–99215 The presenting problem must be of moderate to high severity Documentation  must support the use of a modifier 25

V20.2 must be the primary diagnosis code for the preventive visit Add multiple diagnosis codes for the presenting problem focused evaluation.

THE PREVENTIVE SERVICE E/M VISIT WITH A PROBLEM-ORIENTED SERVICE: AN EXAMPLE

A 52-year-old established patient presents for an annual exam. When you ask about his current complaints, he mentions that he has had mild chest pain and a productive cough over the past week and that the pain is worse on deep inspiration. You take additional history related to his symptoms, perform a detailed respiratory and CV exam, and order an electrocardiogram and chest X-ray. You make a diagnosis of acute bronchitis with chest pain and prescribe medication and bed rest along with instructions to stop smoking. You document both the problem-oriented and the preventive components of the encounter in detail. You should submit 99396, “Periodic comprehensive preventive medicine…, established patient; 40-64 years” and ICD-9 code V70.0, “Routine general medical examination at a health care facility”; and the problem-oriented code that describes the additional work associated with the evaluation of the respiratory complaints with modifier -25 attached, ICD-9 codes 466.0, “Acute bronchitis” and 786.50, “Chest pain” and the appropriate codes for the electrocardiogram and chest X-ray.

Bill Diagnosis code(s) V70.0

Routine exam Procedure code(s) 99396

Preventive service 466.0 786.50

Acute bronchitis  Chest pain 99213-25*

Office outpatient E/M service for established patient 93000

Electrocardiogram 71020

Chest X-ray, PA and lateral

*The level of service represents only an example. The level reported should be determined by the documented history, exam and/or medical decision-making.

CPT Code for Initial Evaluation of New Patient (Bold)

CPT Code for Periodic Reevaluation

99381 – 99391 – Under 1 year

99382 – 99392 – 1-4

99383 – 99393 – 5-11

99384 – 99394 – 12-17

99385 – 99395 – 18-39

99386 – 99396 – 40-64

99387 – 99397 – 65 and over

Code 99420 is specific to administration and interpretation of health risk assessment instruments.

Payers may or may not allow use of this code for behavior-related questionnaires such as the Pediatric Symptom Checklist or one of the longer alcohol- or depression-related questionnaires.

Finally, the last of the preventive medicine codes is 99429, Unlisted Preventive Medicine Service. Practitioners are urged to check with the managed care plan or insurance carrier before using this code.

PREVENTIVE CODES THAT SHOULD GENERALLY BE COVERED AT NO OUT OF POCKET COST FOR BCBSIL HMO MEMBERS  Preventive Medicine Services – Adult Established Patient: 99394 – adolescent (12-17) 99395 – 18-39 years 99396 – 40-64 years 99397 – 65 years and older Preventive Medicine Services – Pediatric Established patient: 99391 – age younger than 1 year 99392 – age 1-4 years 99393 – age 5-11 years

99211 99212 99213 99214 99215 Mutually Exclusive   99391 99392 99393 99394 99395 99396 99397

Therefore, 99211-99215 is submitted with 99391-99397–only 99391-99397 reimburses.

Preventive Medicine Evaluation & Management (E&M) Services

 *  Preventive Medicine E&M services should be reported using the age appropriate code from the Preventive Medicine Services section of the most current CPT manual.

* Services rendered should be reported using 99381-99387 for new patients or 99391-99397 for established patients. These codes include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination.

*  If an abnormality/ies is encountered, or a preexisting problem is addressed in the process of performing a preventive medicine E&M service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a  problem-oriented E&M service, then the appropriate  office/Outpatient code 99201-99215 should also be reported.

Modifier-25 should be added to the Office/Outpatient code to indicate that a significant; separately identifiable E&M service was provided by the same physician on the same day as the preventive medicine service. Note: An insignificant or trivial problem or abnormality that is encountered in the process of performing the preventive medicine E&M service and which does not require additional work and the performance of the key components of a problem-oriented E&M service should not be reported.

Evaluation and management services including new or established patient office or other outpatient services (99201-99215), emergency department services (99281-99285), nursing facility services (99304-99318), domiciliary, rest home, or custodial care services (99324-99337), home services (99341-99350), and preventive medicine services (99381-99397) on the same date related to the admission to “observation status” should not be reported separately.” (AMA7)

“An E&M service is separately reportable on the same date of service as a procedure with a global period of 000, 010, or 090 under limited circumstances…If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.

REIMBURSEMENT GUIDELINES Preventive Medicine Service and Problem Oriented E/M Service

A Preventive Medicine CPT or HCPCS code and a Problem-Oriented E/M CPT code may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. If the E/M code represents a significant, separately identifiable service and is submitted with modifier 25 appended, Oxford will reimburse the Preventive Medicine code plus 50% of the Problem-Oriented E/M code. Oxford will not reimburse a Problem-Oriented E/M code that does not represent a significant, separately identifiable service and that is not submitted with modifier 25 appended.

Preventive Medicine Service and Other E/M Service

A Preventive Medicine CPT or HCPCS code and Other E/M CPT or HCPCS codes may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. However, Oxford will only reimburse the Preventive Medicine CPT or HCPCS code.

Screening Services

The comprehensive nature of a Preventive Medicine code reflects an age and gender appropriate examination. When a screening code is billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Prolonged Services

Prolonged services codes represent add-on services that are reimbursed when reported in addition to an appropriate primary service. Preventive medicine services are not designated as appropriate primary codes for the Prolonged services codes. When Prolonged service add-on codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Counseling Services

Preventive Medicine Services include counseling. When counseling service codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Medical Nutrition Therapy Services

According to CPT, for Medical Nutrition Therapy assessment and/or intervention performed by a physician, report Evaluation and Management or Preventive Medicine service codes. When Medical Nutrition Therapy codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Visual Function and Visual Acuity Screening

The comprehensive nature of a Preventive Medicine code reflects an age and gender appropriate examination. When Visual Function Screening or Visual Acuity Screening is billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Preventive Medicine Service Provided at the Time of Covered Screening Service

A preventive medicine exam, as described by CPT-4 codes (99384 – 99397), includes a comprehensive age and gender appropriate history, examination, counseling/anticipatory guidance/risk-factor reduction interventions, and the ordering of appropriate immunization(s) and laboratory/diagnostic procedures. Sometimes these other elements are performed during the same visit as the Medicare covered services, particularly G0101 and Q0091. The following pie chart illustrates this circumstance.

The following are examples of screening services that are ineligible for separate reimbursement when reported with preventive medicine services, annual GYN examinations and/or problem oriented E/M services:

• G0101 is included in the reimbursement for:

o problem oriented E/M services (99201-99215)*

o preventive medicine services (99381-99397)

o annual GYN examinations (S0610, S0612, or S0613)

• G0102 is included in the reimbursement for:

• Q0091 is included in the reimbursement for:

o preventive medical services (99381-99397)*

o annual GYN examinations (S0610, S0612, or S0613)*

• S0610, S0612, and/or S0613 is included in the reimbursement for:

Coding for a Problem Focused Visit Within an EPSDT Visit

EPSDT codes

99381–99385 or 99391-99395 The components of the EPSDT visit must be provided and documented

PLUS Evaluation and Management (E&M)codes

99203–99215 The presenting problem must be of moderate to high severity.

PLUS Modifier 25*

Documentation must support the use of modifier 25.

PLUS ICD-9 Diagnosis codes

V20.2 or V70.0 must be the primary diagnosis diagnosis code for the visit. Add the diagnosis codes for the presenting problem focused evaluation.

Effective 4/1/2014 EPSDT/Well Child visits are all-inclusive visits. The payment for the EPSDT is intended to cover all elements outlined in the AHCCCS EPSDT Periodicity Schedule (AMPM Exhibilt 430-1). Refer to AMPM Policy 430 for exceptions to the all-inclusive visit global payment rate. Claims must be submitted on CMS 1500 form. Providers must bill for preventative EPSDT services using the preventative service, office or other outpatient services and preventative medicine CPT codes (99381 – 99385, 99391 – 99395) with an EP modifier. EPSDT visits are paid at a global rate for the services specified in AMPM Policy 430. No additional reimbursement is allowed.

Providers must use an EP modifier to designate all services related to the EPSDT well child check-up, including routine vision and hearing screenings.

Providers must be registered as Vaccines for Children (VFC) Program providers and VFC vaccines must be used. Under the federal VFC program, providers are paid a capped fee for administration of vaccines to recipients 18 years old and younger. For VFC claims incurred prior to 1/1/2013, Providers must bill the appropriate CPT code for the immunization with the “SL” (State supplied vaccine) modifier that identifies the immunization as part of the VFC program.

Providers must not use the immunization administration CPT codes 90471, 90472, 90473, and 90474 when billing under the VFC program. Because the vaccine is made available to providers free of charge, providers must not bill for the vaccine itself.

For VFC services incurred on/after 1/1/2013, Section 1202 of the Patient Protection and Affordable Care Act (ACA) requires AHCCCS to modify how providers submit claims for vaccine administration services.

EPSDT CPT codes well-child visits STAGE (Age) NEW PATIENT CPT CODE ESTABLISHED PATIENT CPT CODE

INFANCY (Prenatal – 9 months) 99381 99391 EARLY CHILDHOOD (12 months – 4 years) 99382 99392 MIDDLE CHILDHOOD (5 years – 10 years) 99383 99393 ADOLESCENCE STAGE 1 (11 years – 17 years) 99384 99394 ADOLESCENCE STAGE 2 (18 years – 21 years) 99385 99395 EPSDT CPT codes for sensory screening SERVICE CPT CODE VISION 99173 HEARING (Audio) 92551 HEARING (Pure tone-air only) 92552 Adult annual preventive care visits

New patient

CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older

Established patient

CPT Code 99395: Periodic Preventive Medicine Established Patient 18-39 years CPT Code 99396: Periodic Preventive Medicine Established Patient 40-64 years CPT Code 99397: Periodic Preventive Medicine Established Patient 65 years & older Adolescent annual preventive care visits

CPT Code 99382: Initial Preventive Medicine New Patient age 1-4 years CPT Code 99383: Initial Preventive Medicine New Patient age 5-11 years CPT Code 99384: Initial Preventive Medicine New Patient age 12-17 years

CPT Code 99392: Periodic Preventive Medicine Established Patient age 1-4 years CPT Code 99393: Periodic Preventive Medicine Established Patient age 5-11 years CPT Code 99394: Periodic Preventive Medicine Established Patient age 12-17 years

Preventive Visit Codes Although preventive visit codes will be accepted (99385; 99386; 99387; 99395; 99396; 99397), Medicare does not establish a rate for these codes. Sage will pay 99385 – 99387 at the rate for code 99203. Codes 99395 – 99397 will be paid at the rate for code 99213.

PARTIAL SCREENING and Modifier usage

Different providers may provide segments of the full medical screen. The purpose of this is to increase the access to care for all children and to allow providers reimbursement for those separate screens. When expanded HCY services are accessed through a partial or interperiodic screen, it is the responsibility of the provider completing the partial screening service to have a referral source to refer the child for the remaining components of a full screening service. An unclothed physical and history screen ( CPT codes 99381 52 EP-99385 52EP and 99391 52 EP -9939552EP) includes the first five sections of the age appropriate screening guide including:

• Interval history; • Unclothed physical exam; • Anticipatory guidance; • Laboratory/Immunizations; and • Age appropriate lead screening. Federal regulations require a mandatory blood lead testing by either capillary or venous method at 12 months and 24 months of age. The provider must use the HCY Lead Risk Assessment form.

PARTIAL SCREENING PROCEDURE CODES – UNCLOTHED PHYSICAL & HISTORY (Established Patient) (Provider must complete Sections 1-5 of the HCY Screening Guide)

Procedure Code (Use Age Appropriate Code) Modifier 1 Modifier 2 Fee

99391* 52 EP $20.00 99392* 52 EP $20.00 99393* 52 EP $20.00 99394* 52 EP $20.00 99395* 52 EP $20.00

*Modifier “UC” must be used if child was referred for further care as a result of the screening. DESCRIPTION OF MODIFIERS USED FOR HCY SCREENINGS

* EP – Service provided as part of MO HealthNet early periodic, screening, diagnosis, and treatment (EPSDT). * 52 – Reduced services. Modifier 52 must be used when all the components for the unclothed physical and history procedure codes (99381-99395) have not been met according to CPT. Also used with procedure code 99429 to identify that the components of a partial HCY vision screen have been met. * 59 – Distinct Service. Modifier 59 must be used to identify the components of an HCY screen when only those components related to developmental and mental health are being screened. * UC – EPSDT Referral for Follow-Up Care. The modifier UC must be used when the child is referred on for further care as a result of the screening.

All Preventive CPT CODE AND description Adult preventive care visits New patient CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older

Established patient CPT Code 99395: Periodic Preventive Medicine Established Patient 18-39 years CPT Code 99396: Periodic Preventive Medicine Established Patient 40-64 years CPT Code 99397: Periodic Preventive Medicine Established Patient 65 years & older

Adult annual preventive care visits New patient CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older

Established patient CPT Code 99395: Periodic Preventive Medicine Established Patient 18-39 years CPT Code 99396: Periodic Preventive Medicine Established Patient 40-64 years CPT Code 99397: Periodic Preventive Medicine Established Patient 65 years & older Adolescent annual preventive care visits

New patient CPT Code 99382: Initial Preventive Medicine New Patient age 1-4 years CPT Code 99383: Initial Preventive Medicine New Patient age 5-11 years CPT Code 99384: Initial Preventive Medicine New Patient age 12-17 years

DIAGNOSIS CODES FOR FULL, PARTIAL OR INTERPERIODIC SCREENS

Providers must use V20.2 as the primary diagnosis on claims for HCY screening services. There are two exceptions. CPT codes 99381EP and 99391EP must be billed with diagnosis code V20.2, V20.31 or V20.32. CPT codes 99385 and 99395 must be billed with diagnosis code V25.01-V25.9, V70.0 or V72.31.

FULL SCREENING PROCEDURE CODES (New Patient) Procedure Code (Use Age Appropriate Code)

Modifier 2 Fee 99381* EP $60.00 99382* EP $60.00 99383* EP $60.00 99384* EP $60.00 99385* EP $60.00

PARTIAL SCREENING

Different providers may provide segments of the full medical screen. The purpose of this is to increase the access to care for all children and to allow providers reimbursement for those separate screens. When expanded HCY services are accessed through a partial or interperiodic screen, it is the responsibility of the provider completing the partial screening service to have a referral source to refer the child for the remaining components of a full screening service.

An unclothed physical and history screen (CPT codes 9938152EP-9938552EP and 9939152EP-9939552EP) includes the first five sections of the age appropriate screening guide including:

• Interval history;

• Unclothed physical exam;

• Anticipatory guidance;

• Laboratory/Immunizations; and

• Age appropriate lead screening. Federal regulations require a mandatory blood lead testing by either capillary or venous method at 12 months and

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How to Use Modifier 25

Questions about modifier 25 have increased since  add-on code G2211  was implemented in 2024 to reflect the value primary care physicians provide to patients. Learn how to report modifier 25 correctly so that you can get paid accurately.

What is modifier 25?

• Modifier 25 is a way to identify a “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service,” according to the CPT 2024 code set .
• Modifier 25 may only be appended to evaluation and management services. 

When can it be used?

The E/M service must be significant and distinct from the procedure. The E/M must reflect work that is above and beyond the usual work associated with the procedure or other service. 

Asking the following questions can help determine whether it is appropriate to use modifier 25:

✔️ Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem?

✔️ As documented, could the E/M service stand alone as a billable service?

✔️ Is there a different diagnosis for this portion of the visit?

✔️ If the diagnosis will be the same, did you perform extra physician work that went above and beyond the work of the other service or the typical pre- or postoperative work associated with the procedure?

Modifier 25 should not be used when:

❌ The sole purpose of the encounter is for the procedure (e.g., lesion removal), and there is no documented medical necessity for a separate E/M service. The decision to perform a minor procedure is included in the payment for the procedure and should not be reported as a separate E/M service.

Example: Visit for lesion removal

A patient presents to have a mole assessed and the physician decides to remove it. The decision to remove the mole is included in the procedure code and should not be billed as a separate E/M service.

However, in this same scenario, if the mole has a suspicious, potentially malignant appearance that the physician relates to the patient, in a separate identifiable E/M service, and discusses the possible need for a more extensive procedure if the pathology report comes back positive for malignancy, the E/M visit would be reported with a 25 modifier, along with the procedure code for the lesion removal.

• An E/M is related to and within the global period of a previously performed procedure . This includes minor surgical procedures (defined as a 000 or 010 day global period).
• Patient encounter is for a planned/scheduled minor procedure with no other, significant problems “addressed.”
• Patient encounter is for a preventive service, and there is no significant abnormality found that needs to be addressed within the components of a separate E/M office visit. 

Understand how to properly document and code for E/M services.

What needs to be documented?

• Documentation must demonstrate the medical necessity of the E/M service.
• If possible, physically separate the documentation for the preventive service or procedure from the documentation for the problem-oriented E/M service within the patient’s medical record. 
• Documentation should be able to support each service (i.e., the preventive service or procedure and the E/M) as though it were a standalone service.

Are separate diagnoses required?

No. An E/M service may be reported if it is clinically indicated and reflects work that is above and beyond the preoperative work associated with the procedure — even if both services have the same diagnosis. An example would be a patient who presents with a head laceration and you examine the patient for neurological damage before repairing the laceration.

Is modifier 25 required for E/M services provided at the same encounter as vaccines?

Yes and no. Traditional Medicare does not require modifier 25 for E/M services provided in conjunction with administration of the influenza (Healthcare Common Procedure Coding System [HCPCS] G0008), pneumococcal (HCPCS G0009) or hepatitis B (HCPCS G0010) vaccines. Medicare does require modifier 25 for E/M services provided in conjunction with other vaccine administration codes, including CPT codes 90480, 90460, 90461, 90471, 90472, 90473 and 90474. Private payers may have different policies. The E/M service must be significant and separately identifiable from the vaccine administration. 

Can a preventive medicine visit and a problem-oriented visit be billed in the same encounter?

Yes. If a patient presents for a preventive visit and the physician identifies a new problem or changes to an existing problem that are significant enough to require additional work to perform the key components of the problem-oriented E/M service, both the preventive service and the appropriate office/outpatient E/M service may be reported. Append modifier 25 to the office/outpatient E/M service. While preventive and wellness services are not subject to cost-sharing, the office/outpatient E/M service may be subject to deductible and cost-sharing. If the problem is trivial and does not require additional work, an office/outpatient E/M service should not be reported .

For more information and examples, review the FPM article “ Combining a Wellness Visit with a Problem-Oriented Visit: a Coding Guide .” 

Do all payers follow the same rules for modifier 25?

Not necessarily. Traditional Medicare adheres to the  National Correct Coding Initiative (NCCI) . NCCI edits are updated quarterly. Some Medicare Administrative Contractors have NCCI Lookup tools available ( Novitas ,  CGS Medicare ,  First Coast Service Options ,  Palmetto ).  Private payers often use their own claims editing systems and may not always align with Medicare. Review your payers’ policies or contact your local provider relations representative for more information.  

How is the new add-on HCPCS code G2211 impacted by modifier 25?

As of January 1, 2024, Medicare implemented a new HCPCS code G2211 to reflect the visit complexity associated with providing comprehensive, longitudinal care. 

As part of the implementation of the new HCPCS code G2211, the Centers for Medicare & Medicaid Services (CMS) instituted a policy that prohibits its use when the office/outpatient E/M service is appended with modifier 25. Medicare will not pay for HCPCS code G2211 when modifier 25 is appended to the office/outpatient E/M service. 

The AAFP believes this policy is contrary to the intent of the code and is advocating with CMS to change its policy. However, in the interim, Medicare will deny the G2211 line item on a claim if an E/M with a 25 modifier is also reported on the same date. You can read more about the AAFP’s advocacy efforts  here . Additional information about G2211 is available on the webpage “ G2211 Add-on Code: What It Is and When To Use It .”

Where can I find more information about modifier 25? 

You can find additional information, tools, and tips from the AAFP and the AMA.

• FPM  Getting Paid blog:  Seven quick tips for using modifier 25  (April 2023)
• F PM  article:  Combining a Wellness Visit With a Problem-Oriented Visit: a Coding Guide  (January/February 2022)
• FPM  article:  Understanding when to use Modifier -25  (October 2004)
• FPM  article:  Getting Paid for Screening and Assessment Services  (November/December 2017)
• AMA:  Setting the record straight on proper use of modifier 25
• AMA CPT® Assistant:  Reporting CPT Modifier 25
• CMS Medicare Claims Processing Manual, Chapter 12   and General Correct Coding Policies, Chapter 1 .

Use these G2211 tips to get paid accurately.

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