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Have you encountered this scenario before and what did you do? Were you successful in having the denial reversed? Could we charge this to the patient?
Thank you!
Here are five tips to stop denials and keep your annual visit claims picture perfect this year.
Apply G0438 to second year of coverage
Be wary of applying these codes to new Medicare patients coming in to your doctor’s practice this year. This is because Medicare will only reimburse the initial visit (G0438) during the second year the patient is eligible for Medicare Part B. Simply put, during the first year of the patient’s coverage, Medicare will only cover the Initial Preventive Physical Exam (IPPE), also known as the Welcome to Medicare exam.
CMS limits G0438 to one physician
If your FP sees the patient for the initial visit (G0438) and the patient sees a different physician during the next annual wellness visit, that second physician will only get reimbursement for the subsequent visit (G0439), despite never having seen the patient before.
Reason: CMS has indicated that when a patient returns to the same or new physician in a third year, they might only pay for the subsequent visit. As such, it’s vital that you convey this information to any new physician the patient goes to.
Add preventive services codes, if performed
You can bill the new annual visit codes in addition to any other preventive service such as G0102 and/or Q0091 in the covered year.
Remember: You won’t need to append any modifier for this combination as the G codes are not problem-oriented E/M services to which that modifier applies. If you do report the annual codes with a problem-oriented E/M service (with modifier 25 appended to the problem-oriented code), CMS indicates that this situation should be rare, owing to the nature of the wellness visit requirements which are very time intensive. They also expect that given these requirements, you’ll not bill the patient for a non-covered preventive service in addition.
Document the required elements
Prior to billing the new annual visit codes, the physician or physician team must document certain elements.
CMS waives the deductible and copay
Under provisions listed in the ACA, all plans covered by the rules contained in the Act must offer coverage of a comprehensive range of preventive services that are recommended by experts and the US Preventive Services Task Force (USPSTF) with a grade of A (strongly recommends) or grade B (recommends). This means these codes fall under coverage that doesn’t impose any costsharing requirements.
For more tips to keep your annual visit claims picture perfect, sign up for a one-stop medical coding guide like Supercoder.
We provide you simple, instant connection to official code descriptors & guidelines and other tools for 2010 CPT code, HCPCS lookup that help coders and billers to excel in the work they do every day.
We have a patient is who age 52 but qualifies for Medicare through his disability; he came to office for yearly physical. At first, we submitted claim to Medicare with 99396, received denial due to not a payable code with Medicare. Then corrected claim and resubmitted with G0439 but Medicare denial it again. 
Appreciated if someone could advise the correct code for submission, please!
Thank you very much!