Bob I may be able to shed some light but in order to do that I need the specific codes the doctor used to bill the service. The reason for this is that doctors and patients sometimes use different terminology that may not be the official terminology for a specific service. The billing codes are very specific and tell me exactly what was done. For example one doctor may say annual wellness visit and mean 99387 and another may mean code G0438 or G0439 or even G0403. A well woman exam could be 99397 or just Q0091 and G0101 and sometime the physician may use 99213 or 99214 (inappropriately). I threw out these codes just to show that the billing can be complex and some medical practices may not be completely up to speed on how to bill properly. I want to make sure we are talking about the same thing so I really need the codes billed. If your wife would not mind sharing the CPT codes and diagnosis codes that each doctor used I should be able to help. If they are not on your paperwork call the doctors' office billing department or billing company and they should be able to give you all the codes. Due to HIPAA regulations your wife may need to call. I'll be looking for your response. --Manny

Thank you David. We are still educating doctors. Most providers I come across believe that a AWV is a full routine physical. I have another presentation next week with a large Family Practice to help train the physicians on the differences in the two services and how to document the AWV properly. I think i need to write a more detailed post. Thanks again --Manny

Susan good people are always going to be needed in medical billing and coding. With all the new rules and changes the government and insurance companies will be implementing over the next few years and the transition to ICD-10, I believe there will be job security in our field. The key is to make sure you keep studying and gaining experience. We have several team members here at Capture Billing that have 10-20+ years of medical billing and coding experience and hardly a day goes by where we all don’t learn something new because of the ever changing world of healthcare. Our people read a lot, get ongoing training and have access to great resources in order to do their jobs properly. You really must have a good attention to detail to succeed.

Now taking classes is a great start, but only a start. It will take you another good year or so in a medical billing position, getting hands on experience, to really be able to understand all the concepts. The learning will then continue throughout your career. Remember, Attention to Detail.

Best wishes to you --Manny

Usually you can bill Medicaid as you would commercial insurance. That said, each state can have their own rules on how they want the flu vaccine billed. Additonally, most states have a Vaccines For Children (VFC) program that provides the influenza vaccine at no cost to the patient. You will have to check with your states Medicaid. You should be able to find the billing information on their website.

Hope this helps --Manny

Tricia you are correct that Medicare does not cover 99387 (new patient) or 99397 (established patient) Routine Preventative Medicine Exams, typically referred to as Annual Physicals. If this non-covered services is performed the Medicare patient can be billed directly and an Advanced Beneficiary Notice (ABN) is not needed. Note that some secondary insurance companies do cover the routine physical.

Many providers believe that the Annual Wellness Visit (AWV, G0438 and G0439) is the same as a Routine Preventative Exam. My guess is they are going by what they may have heard in the media that Medicare covers check-ups. The media has been misinforming doctors and patients. A Routine Preventative Exam and AWV are two different services. The AWV has very specific questions that a providers must ask and properly document in order to be able to bill for the service. Take a close look at the requirements in the CMS MLN Matters Publication MN7079 and then take a look at the requirements for 99387/99389 Routine Physical in your CPT book and you will be able to see that the two services are completely different.

I foresee providers documenting the AWV as a Routine Physical and not documenting what is required by the AWV, getting audited and having to return the money (plus penalties) to Medicare because the documentation does not support the G0438 coding.

If your physicians are performing both a 99387/99397 and a G0438/G0439 they should bill for both and get paid for both. --Manny

Rudy, I want to understand clearly, are you saying that if a patient comes into your hospital just for a flu shot and no other service is performed the hospital administration is telling you to bill up to a level 2 visit along with the flu shot? How do you know if its a level 1 or level 2? Are you looking at the chart notes? Level 1 can be for a nurse and level 2 for a physician, NP or PA. Sounds like you are just suppose to pick one regardless?

That said, if the only service you are providing is giving a flu shot, at best you can only bill a level 1 but even that is not billed any more these days. The administration of vaccine code 90471 or G0008 for Medicare is about all you can bill allong with the influenza vaccine codes.

Is there anything else to this story? Are they telling you why? What diagnosis are you using for the E/M visit? Is it different?

I know I am asking more questions but this seams very odd and interesting. --Manny

Elizabeth, yes a provider can bill both an office visit and an AWV on the same day. They are two separate services with different documentation requirements. Medicare should pay for both services if billed properly. --Manny

Yes Tricare does require NDC numbers. I am not sure if Medicare or commercial insurance companies require the NDC. I never looked into it. The reason it does not matter is since we had to include the NDC for Tricare in our computer system the NDC is now automatically picked up and sent with the other vaccine data to all the carriers.

Polly I am not sure if I am answering your question but once you include the NDC in the code tables of your practice management system everyone gets it. --Manny

Valerie, there has got to be more to this Annual Wellness Visit (AWV) denial because the way you have it coded should pay. We have no problem getting paid for claims that are similarly coded.

What was the denial code you received from Medicare? It could be something as simple as frequency (since this is a new patient to your practice they could have had the G0438 with another provider and you need to bill out the G0439 instead) or missing a referring physician, etc.

Let me know what you find. --Manny

You know Linda I think the modifiers are what is messing up the claim. We do not use modifiers on these codes when we submit claims. Check with your local Medicare carrier on the specifics in your jursidiction on how to properly bill these codes and try again.