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Issues with Annual Wellness Visit Claims Can Result in Denials

February 11, 2011:

Starting in January 2011 pursuant to changes made under the Affordable Care Act of 2010 (ACA), the Medicare program began to allow such wellness visits for patients outside of the eligibility for their “Welcome to Medicare” physical examinations.

Although the coverage for these services was announced in December of 2010 and claims processing began in January 2011, some providers submitting claims are running into glitches. In general, Medicare does not cover routine services, and some contractors seem to have an “auto-deny” edit in place whenever diagnosis code G0438 (Annual wellness visit, initial visit) or G0439 (subsequent visit) is billed with V70.0 (Routine general medical examination). However, for the annual wellness visit, code V70.0 would be appropriate.

In late January, the Centers for Medicare and Medicaid Services (CMS) directed its contractors not to automatically deny any claims for the annual wellness visits—claims with codes G0438 or G0439 and an ICD-9-CM code for the reason for the visit, most likely V70.0. National Government Services, a Medicare contractor, has stated that it would reprocess all incorrectly processed claims. Those providers who have had claims improperly denied—regardless of the contractor—may want to determine if the contractor will be reprocessing those claims automatically or if the providers need to resubmit those claims.

The main goal for the annual wellness visit is health promotion and disease detection and to foster the coordination of the screening and preventive services, many of which are already covered under Medicare Part B. The initial annual wellness visit includes:

  • • Establishing an individual’s medical/family history
  • • Establishing a list of current providers and suppliers that are regularly involved in providing medical care to the individual
  • • Measuring an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history
  • • Detecting any cognitive impairment the individual may have as defined in this section
  • • Reviewing the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders
  • • Reviewing the individual’s functional ability and level of safety based on direct observation, or appropriate screening questions or a screening questionnaire
  • • Establishing a written screening schedule for the individual, as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare
  • • Establishing a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits
  • • Furnishing personalized health advice to the individual and referring, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or to community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition
  • • Voluntary advance care planning upon agreement with the individual

The subsequent visit builds upon this initial visit, following up on the services performed initially to continue to promote wellness.


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