PA Resources Portlet
CODING & DOCUMENTATION
EDUCATION & EVENTS
ENROLLMENT & CREDENTIALING
FORMS & MANUALS
POLICIES & GUIDELINES
PROGRAMS & INITIATIVES
PROVIDER NETWORKS & SPECIALTIES
PA Dynamic Rendering
Reporting a Medically Necessary Evaluation and Management Code with an Annual Wellness Visit
There are three Healthcare Common Procedure Coding System (HCPCS) codes available to providers when reporting an Annual Wellness Visit (AWV) exam for Blue Advantage® patients. These codes include:
- G0402 (Welcome to Medicare) for the first 12 months of eligibility (use one time only)
- G0438 (Initial) for the first visit after the 12 months of eligibility (use one time only)
- G0439 (Subsequent) for all subsequent visits after the first two
According to the Current Procedural Terminology (CPT) Coding Guidelines, "If an abnormality is encountered or a pre-existing problem is addressed in the process of performing the AWV, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented Evaluation and Management (E&M) service, then the appropriate office/outpatient code 99201-99215 should also be reported. Modifier -25 should be added to the E&M, office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service."
In addition, if an insignificant issue or abnormality is discovered while performing the AWV and it does not require additional work, an E&M code should not be reported with the AWV code. If both codes are reported, make sure that the documentation supports both services and that there are no overlapping components.
The following are some helpful tips regarding claim submission when reporting an AWV:
- When using the AWV codes, report diagnosis code V70.0 for an adult exam since this is the reason for the visit.
- Next, list all chronic conditions secondary, tertiary, etc. Note: If you have several chronic conditions to add and your Practice Management system has software limitations, use code 99080 to add additional diagnoses. Blue Cross and Blue Shield of Alabama accepts up to 12 diagnoses on a claim.
- When using an E&M code (CPT codes 99201-99215) for a sick visit with the AWV, use the diagnosis code(s) that represents the problem or abnormality to match the additional documentation in the medical record. Remember to add modifier -25 to the E&M code.
- Reminder: Make sure to use the appropriate HCPCS "G" code when submitting your claim for the AWV. This will ensure that your practice receives credit for each patient who receives this service.
- When submitting the HCPCS "G" code(s) for the AWV, be sure to submit it along with a dollar amount so the line item will not reject and you can receive reimbursement and credit for that service.