• How to avoid Medicare annual wellness visit denials

    If you’re seeing a high number of denials for Medicare annual wellness visits (AWVs), you’re not alone. Identifying whether to code for an Initial Preventive Physical Exam (IPPE, or the “Welcome to Medicare” visit), an initial Medicare AWV, or a subsequent Medicare AWV can be tricky.

    Common reasons for denial include the folllowing:

    1. Billing a G0438 (initial Medicare AWV) or G0439 (subsequent Medicare AWV) when the patient has been enrolled in Medicare Part B for 12 months or less. This situation instead calls for billing G0402 (IPPE).

    2. Billing for a Medicare AWV when the patient only has Medicare Part A. They must have Part B coverage as well.

    3. Using the wrong primary diagnosis code. If the primary diagnosis code is problem-oriented (e.g., diabetes or hypertension), Medicare will most likely deny a claim for an AWV, because AWVs are “well visits.” Instead, list a well code (e.g., Z00.0X, “encounter for general adult exam”) as the primary diagnosis.

    The IPPE also has a slightly different set of required components (e.g., advance care planning and visual acuity screening with documentation of results in the note) than the two types of AWVs (e.g., instrumental activity of daily living and assessment of cognitive function).

    Here are some frequently asked questions to help you further navigate the world of AWV billing, as well as a side-by-side comparison of the three types of Medicare wellness visits.


    Q - What is the difference between a Medicare AWV and a preventive visit?

    A - Medicare AWVs consist of three specific visit types statutorily covered by Medicare with no co-pay or deductible. They are the IPPE (the “Welcome to Medicare” visit, G0402), the initial AWV (G0438), and the subsequent AWV (G0439). These visits do not require a comprehensive physical exam. Preventive visits (9938X and 9939X) are covered by commercial/managed care and Medicaid plans and require a comprehensive physical exam. They are also include no co-pay or deductible.

    Q - Can a Medicare patient receive a preventive visit?

    A - Yes, but traditional Medicare does not cover these visits (9938X and 9939X are statutorily prohibited), so patients with that coverage will have to pay 100% out-of-pocket. However, some Medicare Advantage plans cover both Medicare AWVs (G codes) and non-Medicare (commercial) preventive visits (9938X and 9939X). Medicare Advantage patients would need to check their plan benefits to find out if they have coverage for both.

    Q - Is the IPPE the same as the initial AWV?

    A - No, the IPPE is the Initial Preventive Physical Examination, also known as the "Welcome to Medicare" visit (G0402), while the initial AWV (G0438) is the patient’s first Medicare AWV following the IPPE. These are two different types of visits, and billing a G0438 when the patient was actually only eligible for a G0402 is a common cause of denials.

    Q - What diagnosis code should I use to bill a Medicare wellness exam?

    A - Use the Z00 family of codes.

    Q - Do Medicare wellness visits need to be performed 365 days apart?

    A - No. A Medicare wellness visit may be performed in the same calendar month (but different year) as the previous Medicare wellness visit. For example, if a patient had a Medicare AWV on June 30, 2020, then that patient is eligible again on June 1, 2021. If a patient had a Medicare AWV on June 1, 2020, then that patient is also eligible again on June 1, 2021. But if you bill a Medicare AWV for either patient on May 31, 2021, it will be denied, because it is in a different calendar month and too soon.

    Q - Can I bill for a Medicare AWV and a commercial insurance preventive visit for the same patient in the same year?

    A - Yes, you can do this if the patient has both as part of their covered benefits. Some patients have a commercial payer as their primary insurance and Medicare as their secondary.

    Q - Can I perform Medicare wellness visits in skilled nursing facilities or as home visits?

    A - Yes. Just make sure the place of service (POS) on the claim corresponds to the correct location.

    Q - Can I perform a pap smear or pelvic exam during a Medicare AWV?

    A - Yes, and they are both separately billable. Use code Q0091 for the screening pap smear in a Medicare patient. The pelvic exam must be combined with a breast exam and then billed together using G0101. Specific documentation components are required for the G0101.

    Q - If a patient has a managed Medicare plan (non-traditional Medicare), can I still bill a G code (G0402, G0438, or G0439) for a wellness visit?

    A - Yes. Traditional Medicare and all managed Medicare plans will accept the G codes for AWVs.

    Q - Can I bill a routine office visit with a Medicare AWV?

    A - When appropriate, a routine office visit (9920X and 9921X) may be billed with a Medicare AWV. Modifier -25 should be appended to the evaluation and management (E/M) code. Cost sharing will apply to the E/M service, though, just as it would without the Medicare AWV. Make sure patients are aware of this, as some may expect that all services provided on the same day as the Medicare AWV are covered at 100%.

    Which type of Medicare AWV is this?

      IPPE (Welcome to Medicare, G0402) Initial AWV (G0438) Subsequent AWV (G0439)
    How often? Once in a lifetime Once in a lifetime Annually
    Eligibility Within first 12 months of Medicare Part B enrollment 12 months after the IPPE (or if patient did not receive an IPPE during 12-month eligibility window) Every year after the initial AWV
    Minimum time since previous AWV   Not applicable (first visit) At least 11 full months after G0402. (Can be billed when you reach same calendar month as previous year's visit.) At least 11 full months after G0438 or G0439. (Can be billed when you reach same calendar month as previous year's visit.)
    Required physical exam components Height, weight, body mass index (BMI), blood pressure (BP), visual acuity screening (w/ documentation) Height, weight, BMI, and BP (visual acuity screen not required) Weight and BP (height, BMI, and visual acuity screen not required)
    Electrocardiogram (ECG) screening covered? Yes, but co-pay and deductible apply (ECG codes G0403, G0404, and G0405) No No
    Can advance care planning (ACP) be billed separately? No. ACP is included as a mandatory component of this visit. Yes, CPT 99497 and 99498 can be billed separately as long as minimum time requirements are met. Use modifier -33 to avoid co-pay and deductible. Yes, CPT 99497 and 99498 can be billed separately as long as minimum time requirements are met. Use modifier -33 to avoid co-pay and deductible.

    — Vinita Magoon, DO, JD, MBA, MPH, CMQ, Baylor Scott & White Health, Temple, Texas

    Posted on Feb 04, 2021 by FPM Editors

    Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use.