Physician Billing for Wellness Visits vs. Physical Exams Under Medicare

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Written by Jessica Zeff @ Simply Compliance www.simplycomplianceconsulting.com


Navigating the complexities of billing for wellness visits and routine physical exams can be challenging for healthcare providers. A common point of confusion is differentiating between billing for Annual Wellness Visits (AWVs) and routine physical exams. Understanding the distinctions and ensuring proper billing practices can help avoid compliance issues and financial penalties.

Understanding Medicare’s Billing Requirements

Medicare’s billing regulations differentiate significantly between Annual Wellness Visits (AWVs) and routine physical exams, causing widespread confusion among healthcare providers and patients alike. Medicare covers AWVs but not routine physical exams. This distinction is crucial for compliance and patient billing.

Annual Wellness Visits (AWVs): A Closer Look

AWVs are covered under Medicare and focus on preventive care, assessing health risks, and updating personalized prevention plans. They are covered annually after a beneficiary’s first year on Medicare. Unlike routine physicals, AWVs do not require physical examinations but include activities like establishing medical and family history, assessing for potential depression, and reviewing functional ability.

More specifically, AWVs are designed to create a personalized prevention plan for patients. The AWV is focused on health promotion, disease prevention, and detection. Key components of an AWV include:

  • Review of the patient’s medical and family history
  • Development or updating of a list of current providers and prescriptions
  • Measurement of height, weight, body mass index (BMI), blood pressure, and other routine measurements
  • Detection of any cognitive impairments
  • Review of risk factors for depression
  • Establishment of a written screening schedule
  • Provision of personalized health advice and referrals for preventive services.

The Billing Confusion

The confusion often arises when patients expecting a covered AWV receive a physical exam, leading to unexpected charges. Medicare mandates the use of specific HCPCS codes for billing AWVs, prohibiting the use of CPT codes 99381-99397, which are for comprehensive preventive medicine services which Medicare doesn’t cover because they’re considered routine. Providers are encouraged to obtain an Advance Beneficiary Notice (ABN), making patients aware of potential charges for services not covered by Medicare (Pub. 100-04, Chapter 50, section 50.2.1)​​.

Compliance Challenges and Recommendations

Healthcare providers face compliance risks when navigating the intricacies of Medicare billing for wellness visits. It’s essential to adhere to Medicare’s guidelines, ensuring that all components of the AWV are documented and billed correctly. Utilizing a single template for all wellness-related visits can help avoid missing required components and improve compliance​​.

Implications for Practice

To mitigate billing and compliance risks, healthcare providers should:

  • Clearly document the purpose and components of the AWV, distinguishing it from a routine physical exam.
  • Use the correct HCPCS codes for AWVs (G0438 and G0439) and avoid using E/M codes for services not covered under the AWV.
  • Train billing and coding staff to understand the differences between AWVs and routine physical exams and the appropriate codes to use for each.
  • Inform patients about what is included in the AWV versus a routine physical exam to manage expectations and prevent misunderstandings about coverage.

Conclusion

Navigating the billing complexities of Medicare’s AWVs and physical exams requires a clear understanding of the guidelines and proactive patient communication. By adhering to Medicare’s billing requirements and educating patients, healthcare providers can avoid compliance pitfalls and ensure a transparent billing process.