Re: Medicare Physicals - how much it pays

[Guest guest]

Thanks, .

Interesting stuff.

 

Document says...

Billing Requirements

Two new HCPCS codes, G0438 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit, (Short descriptor – Annual wellness first) andG0439 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit, (Short descriptor – Annual wellness subseq) will be implemented January 1, 2011, through the Medicare Physician Fee Schedule Database (MPFSDB) and Integrated Outpatient Code Editor (IOCE).

Other Billing Requirements

Remember that G0438 is for the first AWV only.Thus, submission of G0438 for a beneficiary for whom a claim with code G0438 has already been paid will result in a denial of the later G0438 with a Claim Adjustment Reason Code (CARC) of 149 (Lifetime benefit maximum has been reached for the service/benefit category.) and a Remittance Advice Remarks Code (RARC) of N117 (This service is paid only once in a patient’s lifetime.).

Remember also that the G0438 or G0439 must not be billed within 12 months of a previous billing of a G0402 (IPPE), G0438, or G0439 for the same beneficiary. Such subsequent claims will be denied with a CARC of 119 (Benefit maximum for this time period or occurrence has been reached) and a RARC of N130 (Consult plan benefit documents/guidelines for information about restrictions for this service).

If a claim for a G0438 or G0439 is submitted within the first 12 months after the effective date of the beneficiary’s first Medicare Part B coverage, it will also be denied as that beneficiary is eligible for the IPPE or " Welcome to Medicare " physical. Such claims with G0438 or G0439 will be denied with a CARC of 26 (Expenses incurred prior to coverage) and a RARC of N130.

Locke, MD

 

Here is the link, as promised: http://www.cms.gov/MLNMattersArticles/downloads/MM7079.pdf

 

These little MLN news articles really answer most billing questions.  You can subscribe to them, or simply do a search on the CMS site for “MLN Matters Index” and you can get a list of them.

 

The New to Medicare code is G0402 and I erroneously stated that it is for the first 12 months – it is not.  You must bill that code and only that code for a “physical” if the patient has started Medicare within the past 6 months.  Then you must wait 12 months to do another physical (>365 days is my interpretation of the above article), which would be billed as G0438.  If the patient’s eligibility for Medicare was greater than 6 months ago, you would bill a G0438 for the “physical.”  No one should be coding a G0439 in 2011.  If you do, you are leaving money on the table because the reimbursement for that is less than a G0438.  My understanding is that G0439 is like a “follow-up” to a G0438.

 

Have a great weekend, everyone!

 

(in the San Francisco Bay area that is supposed to have SNOW tonight!!! – will be mixed with rain and not stick to the ground, I’m sure, but it is quite an event around here!)

 

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Pratt

Sent: Friday, February 25, 2011 8:57 AMTo:

Subject: RE: Medicare Physicals - how much it pays

 

 

My understanding of Medicare physicals:

In the first 12 months (expanded from 6 months) of patient’s Part B elibility, you must bill the New to Medicare Physical.  This may be different than G0438?  Not at the office to look up the code.

Then you can bill the G0438 – Annual PPPS (1st visit) – 12 months the New to Medicare Physical OR if this is the 1st Medicare Physical that you are doing (all of our Medicare patients that get a physical in 2011 that are not new to Medicare will get this code).  We’ve been reimbursed about $170 (off the top of my head) for this code.

Then you can bill the G0439 – Follow-up PPPS (2nd+ visits) – again after 12 months from billing G0438.  We will start billing these in 2012 for patients that have gotten the G0438.

When I get to the office, I will find the news article from Medicare and post it, which explains all of this coding.

 

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Locke

Sent: Friday, February 25, 2011 1:59 AMTo: ; Practice Management Issues; Kim Scheuer; Dr. Niebur; Bruce Bowen, MD; Glenn Kotz; Ann Mass; Anne Goyette; Locke; Check; Dr. Zimet

Subject: Medicare Physicals - how much it pays

 

 

In Colorado, it appears...the G0439 (Medicare Annual Physical -- the one AFTER the Welcome to Medicare Physcial), pays...

 

$116.84

 

Of note, in our area, the Welcome Physical G0438 pays - $174.61

 

Also, interesting to see the range of fees for the G0439 Annual Physicals for all the different regions. See bottom.

 

Locke, MD

Here is where to look up your fees for Medicare...

 

http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp

HCPCS CODE

MODIFIER

PROC STAT

CARRIER LOCALITY

NON-FACILITY PRICE

FACILITY PRICE

NON-FACILITY LIMITING CHARGE

FACILITY LIMITING CHARGE

CONV FACT

NA FLAG FOR TRANS NON-FAC PE RVU

NA FLG FOR FULLY IMP NON-FAC PE RVU

NA FLAG FOR TRANS FACILITY PE RVU

NA FLAG FOR FULLY IMP FAC PE RVU

NOT USED FOR MEDICARE

OPPS NON-FACILITY PAYMENT AMOUNT1

OPPS FACILITY PAYMENT AMOUNT1

G0439

　

A

0410201

$106.95

NA

$116.84

NA

33.9764

　

　

NA

　

　

NA

NA

 

No time to show all the various states, but here are the various ranges.

 

NON-FACILITY LIMITING CHARGE

$117.30

$112.37

$150.31

$116.17

$112.02

$135.58

$132.47

$135.47

$137.07

$145.85

$145.99

$139.89

$133.80

$122.40

$122.40

$116.84

$129.30

$133.25

$120.09

$121.02

$123.86

$116.55

$117.87

$113.71

$128.93

$113.37

$123.73

$115.95

$122.59

$114.03

$114.25

$112.68

$113.32

$112.85

$118.31

$113.22

$118.59

$113.63

$123.60

$118.12

$132.62

$123.65

$121.44

$114.96

$116.11

$112.76

$115.89

$115.43

$112.04

$117.17

$113.05

$120.00

$119.70

$132.69

$126.67

$114.15

$136.87

$137.27

$122.44

$134.40

$114.55

$114.50

$116.69

$115.19

$112.51

$117.92

$114.85

$123.90

$114.87

$107.08

$122.53

$113.82

$116.66

$113.49

$116.84

$113.63

$116.16

$117.82

$116.17

$116.50

$117.63

$113.78

$114.52

$116.89

$115.62

$116.94

$124.10

$116.50

$112.28

$114.66

$117.35