Basics of HCPCS code G0402, G0438 & G0439

The Annual Wellness Visit (AWV) is a free annual preventive visit which focuses on providing a personalized prevention plan of services for Medicare Advantage members. The AWV is not a routine physical exam. AWV can be performed by Physician (doctor of medicine or osteopathy), qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist); or medical professional (including a health educator, registered dietitian, nutrition professional or other licensed practitioner), or a team of medical professionals working under the direct supervision of a physician may perform the AWV. However, for Risk Adjustment (RA) purposes the AWV must be completed by a CMS approved provider. HCPCS code G0438 & G0439 are used for reporting Annual Wellness Visit (AWV).

Initial AWV is available to the beneficiary during the second year of eligibility for Medicare. Subsequent AWV are allowed once per calendar year after the initial AWV

E/M service may be billed in addition to the AWV. Report the Current Procedural Terminology (CPT) code with modifier -25.

Description of HCPCS code G0402, G0438 & G0439

G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment

G0438 Annual wellness visit, includes a personalized prevention plan of service (PPPS) first visit

G0439 Annual wellness visit, includes a personalized prevention plan of service (PPPS) subsequent visit

The initial AWV, G0438, is performed on patients that have been enrolled with Medicare for more than one year. A patient is eligible for his subsequent AWV, G0439, one year after his initial visit. Remember that during the first year a patient has enrolled with Medicare, he is eligible for the Welcome to Medicare visit or Initial Preventative Physical Exam (IPPE). This exam is billed using HCPCS code G0402. An Annual Wellness Visit code of G0438 should not be used and will be denied  because the patient is eligible for the Welcome to Medicare visit during the first year of enrollment.

Read also: When to use G0463 HCPCS code 

Difference between IPPE (HCPCS code G0402) & AWV (HCPCS code G0438 & G0439)

Initial Preventive Physical Examination (IPPE)

• Review of medical and social health history and preventive services education
• Covered only one within 12 months of Part B enrollment
• Patient pays nothing (if provider accepts assignment)

Annual Wellness Visit (AWV)

• Visit of develop or update a personalized prevention plan, and perform a health risk assessment
• Covered once every 12 months
• Patient pay nothing (if provider accepts assignment).

Read also: Medical Terminology used in Medical Billing

Billing of HCPCS code G0402, G0438 & G0439

Remember that G0438 is for the first AWV only. Thus, submission of G0438 for a beneficiary for whom a claim with code G0438 has already been paid will result in a denial of the later G0438 with a Claim Adjustment Reason Code (CARC) of 149 (Lifetime benefit maximum has been reached for the service/benefit category.) and a Remittance Advice Remarks Code (RARC) of N117 (This service is paid only once in a patient’s lifetime.)

Remember also that the G0438 or G0439 must not be billed within 12 months of a previous billing of a G0402 (IPPE), G0438, or G0439 for the same beneficiary. Such subsequent claims will be denied with a CARC of 119 (Benefit maximum for this time period or occurrence has been reached) and a RARC of N130 (Consult plan benefit documents/guidelines for information about restrictions for this service)

When patients receive their AWV, it is often accompanied by one or more evaluation and management (E&M) services. If you provide what can be defined as a “significant, separately identifiable medically necessary E&M service” in addition to the annual wellness visit, CPT codes 99201-99215 may be reported. Along with code G0438 or G0439, CPT code modifier -25 must be appended to the medically necessary E&M service. CPT guidelines define the 25 modifier as “Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”  

Before coding for one or more E&M services, first determine whether some of the components of the medically necessary E&M service, such as a portion of the history exam, were part of the annual wellness visit. If that’s the case, these components should not be included when determining the most appropriate level of the billable E&M service. 

If you’ve been researching how to code and bill for the annual wellness visit, you may have seen HCPCS code G0468. Unless you work in a federally qualified health center (FQHC), this HCPCS code would not apply. G0468 is used by FQHCs to code and bill for AWVs and IPPEs. Its long descriptor is “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,” while its short descriptor is “FQHC visit, IPPE or AWV.”

References:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf

https://capturebilling.com/medicare-g0438-g0439-two-new-annual-wellness-visit-codes/

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7079.pdf

https://providers.amerigroup.com/Documents/ALL_CARE_AW_RiskAdjustmentWellnessFactSheet.pdf