Medicare Wellness with E/M on same day

What are the guidelines for billing an annual Medicare Wellness exam with an E/M on the same day?

re: Medicare Wellness with E/M on same day

Everything I have learned you have to be able to prove the E&M visit is medical neccssary from the Wellness visit within the documentation. You will also need a modifier.

re: Medicare Wellness with E/M on same day

This is always a tricky one. I just happen to have several examples. My most recent question was billing a 99211-25 with the AWV simply becuz the provider ordered labs. No other "significant or separately identifiable" issue documented. The thought is that the pt's chronic conditions support the lab order. We are researching this but it seems that if this is ok, it should be a level 2 visit not back office. I can tell you that United Healthcare (if they're in your area) never pays the 99211 for any of their products. MLN offers information titled Medicare preventive services on their website. The issue date is 2012 for the IPPE, Initial AWV and subsequent AWV. I use this as a guide everytime as well as an audit sheet to support the office E/M code. Good luck

re: Medicare Wellness with E/M on same day

CMS states that both are payable, but you can't use the documentation from the wellness visit to select the level of service for the AWV. But, the AWV doesn't require HPI, ROS, Exam, or A/P related to a specific problem.

From the manual:
H. Reporting a Medically Necessary E/M Service Furnished During the Same Encounter as an IPPE or AWV
When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT® codes 99201 – 99215 may be reported depending on the clinical appropriateness of the circumstances. CPT® Modifier –25 shall be appended to the
?medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whichever applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).

re: Medicare Wellness with E/M on same day

So if the doctor orders lab work prior to the AWV and discusses the lab results with the patient we can bill for a separate E/M? This is such a gray area. Thanks for your response!

re: Medicare Wellness with E/M on same day

[So if the doctor orders lab work prior to the AWV and discusses the lab results with the patient we can bill for a separate E/M? This is such a gray area. Thanks for your response!]

That depends on why the labs were done. If they were for screening purposes or are regularly ordered for management of a chronic condition, then no. If they were for a specific problem and used for diagnostic purposes then yes. This would also apply to any labs ordered during the AWV.

re: Medicare Wellness with E/M on same day

if pt comes in for wellness and complains of a new problem or a change in a current problem such as adjusting a certain med then yes you can bill E/M code along with physical with the added modifier 25.