Tips and Techniques for accurate and improved coding of your Annual Wellness Visits and follow-up care.
Coding Question “Blog”
Featuring Mary Lindahl
Note: This blog discusses coding issues focused on the Medicare Annual Wellness Visit (AWV). All topics contained here relate to the AWV in some fashion. The answers are provided by Mary Lindahl, who is a very experienced and established coding expert. Mary is available for private consults.
Frequently Asked Questions from the March 28, 2012 Medicare Preventive Services National Provider Call: The Initial Preventive Physical Exam and the Annual Wellness Visit
Click Here to View this Document
Q: Can you give me a good explanation of when to use the Modifier -25? More specifically, if I am seeing my patient for an Annual Wellness Visit and there is an additional reason to treat the patient for some chronic or acute reason, how would I document the two encounters so I got paid for both?
A: See this article for your answer.
Q: What services may be billed and performed concurrent with the Annual Wellness Visit?
A: Some of the services that Medicare covers are currently listed on WellTrackONE’s website in a previous blog that I had written. The information comes directly from CMS. The link to the document is http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1 .pdf. The blog was done months ago so there are a few things that Medicare has added.
Medicare has added an additional service beginning February 5, 2015. This service is Lung Cancer Screening Counseling and Annual Screening for Lung Cancer with Low Dose Computed Tomography. Medicare began covering lung cancer screening counseling and a shared decision making visit, and for appropriate beneficiaries, annual screening for lung cancer with low dose computed tomography (LDCT). More information about this screening can be found at http://www.cms.gov/medicarecoverage-database/details/nca-decision-memo.aspx?NCAId=274.
As far as what can billed at the same time as the AWV, there is no specific answer to that. Most services below can be billed along with the AWV as long as medical necessity is met and the documentation supports it. The depression screening would be an example of a service that cannot be billed at the same time as some of the other services. In your example above, you asked if G0438, 96103, 96120, G0444, G0442, and G0328 can be billed together. Per correct coding edits, G0438 and G0444 cannot be billed together but all the other codes can. I would suggest that coding combinations be run through a CCI editor in order to determine if they can be billed and paid for at the same time as an AWV.
Click to Read this Document on Billable Codes.
Q: I just completed the Annual Wellness Visit and while my patient is still in the exam room, the Clinical Triggers of WellTrackONE have told me that the patient is hypertensive. Can I now bring the patient into our EKG room and conduct an EKG? If so, how would I code that visit for best reimbursement?
A: An EKG can be billed in addition to the AWV using code 93000 but the diagnosis would need to be considered medically necessary. You would need to check the local coverage determinations (LCD) of the Medicare carrier in your area to be sure the ICD-10 codes are showing as payable. If you are performing the EKG for a non-covered diagnosis, you would need to obtain an advance beneficiary notice (ABN) prior to rendering the EKG in order to bill the patient after receiving the Medicare denial.
The medical record would also need to reflect that the provider was ordering an EKG and the reason for ordering it, as well as the results of the test.
Q: I just completed the Annual Wellness Visit and the WellTrackONE Clinical Triggers have told me that the patient has high to severe risk of cardiovascular disease (CVD). I would like to run a lipid panel. Assuming my physician has a standing order for this protocol, can I bring the patient into the lab and order a lipid panel? If so, how would I code that visit for best reimbursement?
A: First, standing orders for a protocol must be discussed. Medicare has very specific requirements around this type of language.
Medicare will consider payment for appropriately documented covered services that are reasonable and necessary for the beneficiary, given his/her clinical condition. Medical necessity is the driving force for the payment of any Medicare service. If a service is not medically necessary, it cannot be paid by Medicare. Providers need be cognizant of the various meanings represented by use of the term “standing orders.” Some understand this to mean recurring orders specific to the care of an individual patient, while others understand this as routine orders for services delivered to a population of patients. The following can help you understand the various uses of “standing orders.”
Routine orders are orders for those services and treatments that are applied to patients who have the same or similar medical condition(s). These frequently called “routine, protocol or standing orders” are based on an assessment of the impact of a given condition in the population of patients with that condition (medical illness or injury) and are widely applied to those patients. Medicare defines any order(s) that does not specifically address an individual patient’s unique illness, injury or medical status, as not reasonable and necessary. As is required by law, Medicare does not accept such “standing orders” as supporting medical necessity for the individual patient. Services related to population-based or condition-based orders are not reimbursable.
For physician services, Medicare may reimburse “standing orders” that are specific to an individual patient’s treatment. For example: the standing order “Evaluate this patient’s decubitus ulcer on a daily basis for signs of infection i.e. drainage, odor, size and staging prior to changing dressing.”
Reimbursement of tests or services provided under a standing order for a recurring or serial evaluation is subject to medical necessity review. All such orders must be written for a specific patient, and each instance of the test or service must be necessary. Each result must be reviewed with appropriate action taken by the treating physician, including any appropriate change in the frequency or duration of testing.
Treatment protocols may be reimbursable since these protocols are individualized to each patient. For example, the use of chemotherapeutic drug protocols, that suggest drugs, dosage ranges, frequency and/or duration specifically ordered for an individual patient.
In some circumstances, a standing order for a recurring lab test that is specific to the needs of an individual patient may be reimbursable. (See requirements below.) Preprinted orders are not covered by Medicare. However, preprinted or electronic lists of potential orders are permitted if the provider individually affirms, defines, or otherwise modifies each component as appropriate for an individual patient’s clinical circumstances.
Standing orders for recurring diagnostic tests may be appropriate when all of the following conditions are met:
– Each ordered test must be appropriate and necessary for the individual patient’s clinical circumstances.
– The frequency and number of repeated testing must not be greater than medically necessary.
– The diagnosis must be indicated for each test with sufficient clarity to permit accurate ICD-10-CM coding to the highest level of specificity.
– The treating physician must review each test’s result, making any indicated adjustments in frequency and number of repeated studies.
– All lab tests must be reviewed and documentation must support that the appropriate clinical action was taken.
Examples of appropriate, recurring diagnostic tests under Medicare include:
– Repeat cardiac enzymes to rule out acute ischemia.
– Prothrombin times for a patient on chronic warfarin.
In relation to blood glucose monitoring, CMS has specific instructions in Change Request (CR) 5443:
Medicare separately pays for a blood glucose test only when the service meets all of the conditions of payment for a test payable under the clinical laboratory fee schedule including that the test must be ordered by the physician who is treating the beneficiary and the physician must use the results in the management of the beneficiary’s specific medical condition. Regulation states that for payment to be made for a blood glucose test under Medicare Part B, a physician must certify that each test is medically necessary and that a standing order for many tests over a time period is not sufficient documentation. Payment for nursing care glucose monitoring is encompassed under Medicare Part A and other payment methods.
If the “standing order” qualifies under the above guidelines and the reason for doing the test is well documented in the patient’s record, then the test can be performed. As with the EKG, the diagnosis would need to be considered medically necessary. You would need to check the local coverage determinations of the Medicare carrier in your area to be sure the ICD-10 codes are showing as payable. If you are performing the service for a non-covered diagnosis, you would need to obtain an advance beneficiary notice (ABN) prior to rendering the service in order to bill the patient after receiving the Medicare denial. The appropriate code to bill for a lipid panel would be 80061.
Q: I just completed the Annual Wellness Visit and the WellTrackONE Clinical Triggers have told me that the patient has high to severe risk of diabetes. I would like to run a series of tests to include an HbA1c. Assuming my physician has a standing order for this protocol, can I bring the patient into the lab and order these tests? If so, how would I code that visit for best reimbursement?
A-1: Please see question above for definition of “standing orders”.
A-2: Please see questions above for medical necessity and ABN information as well as documentation requirements.
Lab tests, including A1C can be billed if medically necessary. The list of covered ICD-10 codes is very limited for A1C testing (83036) so refer to your local carriers LCD and national NCD. A more appropriate initial screening test may be glucose; quantitative, blood (82947) or glucose; blood, reagent strip (82948).
Q: I just completed the Annual Wellness Visit and the WellTrackONE Clinical Triggers have told me that the patient has high to severe risk of Mild Cognitive Impairment because she did not pass several of the clock face tests. I would like to conduct the MOST-96120 cognitive analysis test to further evaluate the patient’s cognitive processes. Assuming my physician has a standing order for this protocol, can I administer this test at the point of care? If so, how would I code that visit for best reimbursement?
A-1: Please see question above for definition of “standing orders”.
A-2: Please see questions 1 and 2 for medical necessity and ABN information as well as documentation requirements. Refer to LCD and NCD guidelines.
Approved providers of code 96120 are:
a. Physicians (MD/DO)
b. Clinical psychologists
c. Clinical Social Workers
d. Nurse practitioners
e. Clinical Nurse Specialists
f. Physician Assistants
g. Other providers of mental health services licensed or otherwise authorized by the state in which they practice (e.g., licensed clinical professional counselors, licensed marriage and family therapists). These other providers may not bill Medicare directly for their services, but may provide mental health treatment services to Medicare beneficiaries under the “incident to” provision.
Documentation: The medical record must indicate the presence of mental illness or signs of mental illness for which psychological testing is indicated as an aid in the diagnosis and therapeutic planning. The record must show the tests performed, scoring and interpretation, as well as the time involved.
Comments: These codes do not represent psychotherapeutic modalities, but are diagnostic aids. Use of such tests when mental illness is not suspected would be a screening procedure not covered by Medicare. Each test performed must be medically necessary. Therefore, standardized batteries of tests are not acceptable unless each test in the battery is medically necessary
96120 describes testing which is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. Examples of problems that might lead to neuropsychological testing are:
1. Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild head injury, anoxic injuries, AIDS dementia)
2. Differential diagnosis between psychogenic and neurogenic syndromes
3. Delineation of the neurocognitive effects of central nervous system disorders
4. Neurocognitive monitoring of recovery or progression of central nervous system disorders; or
5. Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders.
The medical record must document that the guidelines outlined above in the “Documentation” and “Comments” sections were followed.
Q: I just completed the Annual Wellness Visit and the WellTrackONE Clinical Triggers have told me that the patient has high to severe risk of depression. I would like to conduct a telehealth assessment with a psychiatrist. Assuming my physician has a standing order for this protocol, can I move the patient to a private room and set up this assessment consult? If so, how would I code that visit, as the PCP, for best reimbursement?
A: Please see question above for definition of “standing orders”.
Please see questions above for medical necessity and ABN information as well as documentation requirements.
Medicare pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via a telecommunications system. For eligible telehealth services, the use of a telecommunications system substitutes for an in-person encounter.
An originating site is the location of an eligible Medicare beneficiary at the time the service being furnished via telecommunications system occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in:
A rural Health Professional Shortage Area, either located outside of a Metropolitan Statistical Area (MSA) or in a rural census tract, as determined by the Office of Rural Health Policy within the Health Resources and Services Administration (HRSA);
A county outside of a MSA.
You can access HRSA’s website tool to determine a potential originating site’s eligibility for Medicare telehealth payment at http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth on the Centers for Medicare & Medicaid Services (CMS) website.
Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014. You should bill the MAC for the originating site facility fee, which is a separately billable Part B payment.
Q: Will Medicare pay for a patient to get transportation to and from the doctor’s office so they can get their Annual Wellness Visit?
A: Neither Medicare Part A or B covers routine transportation for a patient to or from home in non-emergency situations. Therefore, Medicare would not cover transportation to a doctor’s office for any services.
Q: Can chiropractors perform and get reimbursed for the AWV for their Medicare patients?
A: Medicare does not allow chiropractors to perform or receive reimbursement for the AWV. Medicare only allows a physician (a doctor of medicine or osteopathy), a qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist), or a medical professional (a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of such medical professionals who are working under the direct supervision of a physician. There must be physician involvement and chiropractors are not considered physicians by Medicare.
Q: My patient’s AWV shows a severe risk factor for cardiovascular disease (CVD). I would like to bring the patient back for a follow-up visit, order labs and possibly an echo. Can I bill for a 99214 during the follow-up visit if I document at least 4 elements of HPI, 2 systems reviewed (ROS) and document family, medical and social history?
A: 4 elements of HPI, 2 ROS, past medical, family, and social history documentation would support the history portion of the visit. In addition, either an exam or plan must be documented as a 99214 requires 2 of the 3 required components.
If an exam is documented, it would require a detailed exam which consists of 5 to 7 affected body area(s) or related organ system(s).
If a plan is documented, it would require moderate complex decision making which consists of 3 points for number of diagnosis or treatment options, 3 points for amount and/or complexity of data reviewed, and moderate risk of complications and/or morbidity or mortality.
Q: My doctor would like us to draw blood when the patient is here for their Annual Wellness Visit. Can we do that? How would we bill it to Medicare?
A: Yes, this can be done. The provider must place an order for the labs that he/she would like done. The appropriate CPT/HCPCS codes for the blood work that was done and the venipuncture would then need to be billed to Medicare.
Q: When my patient is here with my nurse getting his AWV, what other screening tests can I do with the patient on the same day as the AWV?
A: An annual physical can be done the same day as an AWV but it will not be reimbursed by Medicare. Some secondary payers and Medicare Advantage plans do cover annual physicals. In addition, these can be performed:
Cardiovascular screening blood tests – can be performed every 5 years – 80061 lipid panel, 82465 cholesterol, 83718 lipoprotein, and 84478 triglycerides
Diabetes screening blood tests – Two screening tests per year for beneficiaries diagnosed with pre-diabetes, one screening per year if previously tested, but not diagnosed with pre-diabetes, or if never tested – 82947 glucose; quantitative blood (except reagent strip), 82950 glucose; post-glucose does (includes glucose), or 82951 glucose; tolerance test (GTT0, 3 specimens (includes glucose)
Screening pap tests and screening pelvic examinations – can be performed annually if at high risk for developing cervical or vaginal cancer, or childbearing age with abnormal Pap test within past 3 years or every 24 months for all other women – Q0091 screening pap smear; obtaining, preparing and conveyance to lab and G0101 cervical or vaginal cancer screening; pelvic and clinical breast examination.
Colorectal cancer screening – Fecal occult blood test (FOBT), immunoassay, 1-3 simultaneous or 82270 FOBT (blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection) – FOBT may be billed every year.
Prostate cancer screening – Annually – G0102 digital rectal exam (DRE) and G0103 prostate specific antigen test (PSA).
Tobacco/smoking cessation counseling – Two cessation attempts per year; each attempt includes a maximum of four intermediate or intensive sessions, up to eight sessions in a 12-month period. G0436 smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes or G0437 smoking cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes
Human Immunodeficiency Virus (HIV) screening – annually for patients at high risk. G0432 infectious agent antibody detection by enzyme immunoassay (EIA) technique, G0433 infectious agent antibody detection by enzyme-linked immunosorbent or G0435 infectious agent antibody detection by rapid antibody test.
Intensive behavioral therapy (IBT) for cardiovascular disease – annually – G0446 intensive behavioral therapy to reduce cardiovascular disease risk, individual, face-to-face, annual, 15 minutes.
Screening and behavioral counseling interventions in primary care to reduce alcohol misuse – annual for G0442 and four times per year for G0443. G0442 annual alcohol misuse screening, 15 minutes and G0443 brief face-to-face behavioral counseling for alcohol misuse, 15 minutes.
Screening for depression – annually – G0444 annual depression screening, 15 minutes.
Sexually Transmitted Infections (STIs) Screening and High Intensity Behavioral Counseling (HIBC) to Prevent STIs – One annual occurrence of screening for chlamydia, gonorrhea, and syphilis in women at increased risk who are not pregnant; One annual occurrence of screening for syphilis in men at increased risk; Up to two occurrences per pregnancy of screening for chlamydia and gonorrhea in pregnant women who are at increased risk for STIs and continued increased risk for the second screening; One occurrence per pregnancy of screening for syphilis in pregnant women; up to two additional occurrences per pregnancy if at continued increased risk for STIs; One occurrence per pregnancy of screening for hepatitis B in pregnant women; one additional occurrence per pregnancy if at continued increased risk for STIs; or Up to two HIBC counseling sessions annually.
86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810 – Chlamydia
87590, 87591, 87850 – Neisseria gonorrhoeae
87800 – Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique
86592 – Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)
86593 – Syphilis test, non-treponemal, quantitative
86780 – Treponema pallidum
87340, 87341 – Hepatitis B (hepatitis B surface antigen)
G0445 – Semiannual high intensity behavioral counseling to prevent STIs, individual, face-to-face, includes education skills training & guidance on how to change sexual behavior
Intensive Behavioral Therapy (IBT) for Obesity – One visit every week for the first month; One visit every other week for months 2 – 6; and One visit every month for months 7 – 12, if certain requirements are met. At the 6-month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed. To be eligible for additional face-to-face visits occurring once a month for an additional 6 months, beneficiaries must have lost at least 3kg. For beneficiaries who do not achieve
a weight loss of at least 3kg during the first 6 months, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period – G0447 – Face-to-face behavioral counseling for obesity, 15 minutes.
Q: After the AWV, my WellTrackONE report shows a high risk of diabetes, an out-of-range B/P and an excessive BMI for my patient. I want to start a series of weight loss counseling sessions with my patient. How do I bill for these sessions?
A: See above question and answer under Intensive Behavioral Therapy (IBT) for Obesity.
Q: During the weight loss counseling sessions, can I also bill for smoking cessation counseling?
A: Yes, as long as frequency and coverage requirements are met. See above question and answer under Tobacco/smoking cessation counseling.
Q: Can a patient get their flu shot at the same time they get their AWV?
A: Yes this can be done. The provider must place an order for the flu shot if not being done by him/her personally. The appropriate CPT/HCPCS codes for the flu shot would then need to be billed to Medicare.
Q: Can a patient go over their blood work results at the same time they get their AWV?
A: Yes. Depending upon what is documented; problems determined vs. all normal, this would be billed as preventive medicine visit or an office visit with a 25 modifier.
Q: Can a patient get medication refills at the same time they get their AWV?
A: Possibly. Depending upon documentation, this may be billed as an office visit with a 25 modifier. Just refilling medications would not qualify as supporting using a 25 modifier.
Q: My patient is scheduled to see the doctor for a follow-up visit for their A fib diagnosis. Can I administer the AWV at the same time the patient has that follow-up? How would I bill Medicare?
A: Yes. Depending upon documentation, the follow-up visit for the A fib may be as an office visit with a 25 modifier. The AWV would be billed as well using the appropriate AWV code.
Q: Once the Annual Wellness Visit has been completed and documented and assuming the doctor gets the report the next day showing a list of significant risk factors for Coronary Heart Disease and Colorectal Cancer:
– He or She brings the patient back in for a follow-up to further diagnose these conditions. S/he spends 35 minutes with the patient and orders several labs and echocardiogram tests
– What E&M code can s/he use for this visit?
– What HPI would s/he document for the visit, if any?
– After the test results come back, the doctor brings the patient back in because several of the results are out of limits. He spends 40 minutes with the patient.
– What E&M code can s/he use for this visit?
– Should s/he split the visits up between the workup for the CHD and the workup for the colorectal cancer?
A: If the 35 minutes was spent counseling and/or coordination of care for the patient and the time is documented accordingly, a 99214 could be billed. If time is not spent counseling and/or coordinating care, then the appropriate level would be determined by the history, exam, and medical decision making/plan that were documented.For an established patient, 2 of 3 elements, history, exam, and medical decision making/plan, must be documented.
Same as above, if the 40 minutes was spent counseling and/or coordination of care for the patient and the time is documented accordingly, a 99215 could be billed. If time is not spent counseling and/or coordinating care, then the appropriate level would be determined by the history, exam, and medical decision making/plan that were documented.
For patient convenience, workups can be performed on the same day but only one evaluation and management code may be billed.
Q: Can you cite the general (or specific) requirements of using the 99211 CPT code?
A: Code 99211 describes a face-to-face encounter with a patient consisting of elements of both evaluation (requiring documentation of a clinically relevant and necessary exchange of information) and management (providing patient care that influences, for example, medical decision making or patient education). Documentation must be legible and include the identity and credentials of the servicing provider. This code does not require the presence of a physician and is typically used by support staff (i.e. nursing).
Code 99211 should not be used to bill for:
– Administering routine medications by physician or staff whether or not an injection or infusion code is submitted separately on the claim
– Checking blood pressure when the information obtained does not lead to management of a condition or illness
– Drawing blood for laboratory analysis or for a complete blood count panel, or when performing other diagnostic tests whether or not a claim for the venipuncture or other diagnostic study test is submitted separately
– Making telephone calls to patients to report lab results or to reschedule patient procedures
– Performing diagnostic or therapeutic procedures (especially when the procedure is otherwise usually not covered/not reimbursed, or payment is bundled with reimbursement for another service) whether or not the procedure code is submitted on the claim separately
– Reporting vaccines
– Writing prescriptions (new or refill) when no other evaluation and management is needed or performed.
Q: If a patient comes into the office to have their meds refilled, can an AWV be conducted at that time and billed successfully to Medicare?
A: Yes, as long as the visit for their med refill qualifies for the use of modifier 25 (significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).
Medically necessary services provided on the same day as an AWV would qualify for payment.
Q: Can an AWV be conducted during a home visit?
A: According to CMS, they accept the 99341-99350 codes with G0438/G0439, but we would like clarification on what documentation is needed.
All 3 of the key components, history, examination, and medical decision making, would need to be documented in order to bill for code range 99341-99345. Codes 99347-99350 would need 2 of the 3 key components documented.
All the components of an AWV would need to be documented in order to bill for codes G0438 and G0439. The first AWV includes the following elements:
– a Health Risk Assessment (HRA),
– establishment of an individual’s medical and family history,
– establishment of a list of current clinicians and suppliers that regularly provide care to the beneficiary,
– measurement of blood pressure, height, weight, or waist circumference, if appropriate,
– detection of any cognitive impairment,
– a review of potential risk factors for depression, functional ability, and level of safety,
– establishment of a written screening schedule, such as a checklist for the next 5 to 10 years,
– a list of the risk factors and conditions for which interventions are recommended, and
– provision of personalized health advice and referrals for health education and preventive counseling.
Subsequent AWVs include the following elements:
– measurement of weight, blood pressure, and other measurements deemed appropriate;
– an update to medical and family history;
– an update to the list of providers, suppliers, and medications;
– a review of the initial personal risk assessment;
– detection of any cognitive impairment;
– an updated screening schedule; and,
– a review and update to list of referral services to help intervene and treat potential health risks
The elements of the AWV must not be replicated in the medically necessary home visit service.
Modifier -25 (significant, separately identifiable service)would need to be applied to the medically necessary E/M service to be reimbursed for both services.
Q: If after the AWV, the WellTrackONE Clinical Triggers indicate that the patient should watch a short video on heart disease (because they have risk factors for heart disease as indicated by WT1’s Clinical Triggers), is there any kind of billing code that can be used for the time it takes to show that video to the patient?
A: We are thinking code 99211 would be appropriate to use for all videos shown to the patient and that the provider could actually bill Medicare for an additional professional component service just for showing the video as long as they document it correctly. We found a guide that speaks about this but would like a professional opinion. http://www.aafp.org/fpm/2004/0600/p32.html
It would not be appropriate to bill code 99211 for a patient watching a video. Code 99211 requires
Per information from the above link, “Generally, this means that the patient’s history is reviewed, a limited physical assessment is performed or some degree of decision making occurs. If a clinical need cannot be substantiated, 99211 should not be reported. For example, 99211 would not be appropriate when a patient comes into the office just to pick up a routine prescription.” Having a patient watch a video would not involve reviewing the patient’s history, a physical assessment or some degree of decision making.
As well, when 99211 is billed on the same date of service as another billable service it must meet the requirements for billing the modifier 25 (Significant, Separately Identifiable Evaluation and Management). This modifier indicates, “the patient’s condition required a significant, separately identifiable E/M above and beyond the other service provided or beyond the usual pre- or postoperative care associated with the procedure.” The patient watching a video would not justify the use of modifier 25.
Q: I’ve read that Medicare will allow AWVs in 2015 to be completed by telehealth (video). Do you have any specific guidelines that we need to follow in order to have these completed satisfactorily?
A: Specific scenarios we would like a reading on:
– Patient in their home with an iPad connected by telehealth to physician’s office. Nurse at other end conducting the visit.
– Patient in their home with a traveling nurse and an iPad connected by telehealth to physician’s office. Nurse at other end conducting the visit.
HCPCS codes G0438 (annual wellness visit; includes a personalized prevention plan of service (pps), initial visit; and, G0439 (annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit) have been added to the list of covered telehealth services for 2015.
Several conditions must be met in order for Medicare payments to be made for telehealth services under the Physician Fee Schedule (PFS). Specifically, the service must be on the list of Medicare telehealth services and meet all of the following additional requirements for coverage:
– The service must be furnished via an interactive telecommunications system.
– The practitioner furnishing the service must meet the telehealth requirements, as well as the usual Medicare requirements.
– The service must be furnished to an eligible telehealth individual.
– The individual receiving the services must be in an eligible originating site.
When all of these conditions are met, Medicare pays an originating site fee to the originating site and provides separate payment to the distant site practitioner furnishing the service.
But, the rules for originating sites did not change. An originating site is the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs.
The final rule from CMS published in the Federal Register on 11/13/14 states:
Originating sites, which can be one of several types of sites specified in the statute where an eligible telehealth individual is located at the time the service is being furnished via a telecommunications system, are paid a fee under the PFS for each Medicare telehealth service. The statute specifies both the types of entities that can serve as originating sites and the geographic qualifications for originating sites. With regard to geographic qualifications, § 410.78(b)(4) limits originating sites to those located in rural health professional shortage areas (HPSAs) or in a county that is not included in a metropolitan statistical areas (MSAs).
Historically, we have defined rural HPSAs to be those located outside of MSAs. Effective January 1, 2014, we modified the regulations regarding originating sites to define rural HPSAs as those located in rural census tracts as determined by the Office of Rural Health Policy (ORHP) of the Health Resources and Services Administration (HRSA) (78 FR 74811). Defining ‘‘rural’’ to include geographic areas located in rural census tracts within MSAs allows for broader inclusion of sites within HPSAs as telehealth originating sites. Adopting the more precise definition of ‘‘rural’’ for this purpose expands access to health care services for Medicare beneficiaries located in rural areas. HRSA has developed a Web site tool to provide assistance to potential originating sites to determine their geographic status. To access this tool, see the CMS Web site at www.cms.gov/telehealth/.
Q: Have you read anything about the Annual Wellness Visit being compulsory in 2016?
A: No, not yet.