With just two Medicare exam codes, a physician raised her revenue by $45,320. “So many services that patients are eligible for, like preventative care visits, don’t get utilized by providers, and many are already performing the services,” says Julie Thompson, billing supervisor at MediSYS.
In this provider’s case, it was Medicare’s annual wellness visits. When a patient first becomes active in Medicare Part B, they allow a Welcome to Medicare Visit, also called the Initial Preventive Physical Examination (IPPE). It must be performed within the first 12 months of the patient’s activation and is allowed only once in the patient’s lifetime. Using code G0402, it allows up to a $154.28 reimbursement.
The exam covers much of what physicians are likely covering with their patients already. The provider must review the patient’s medical and social history, including their physical activity, tobacco use, and diet, plus review potential risk factors for depression and mood disorders, and functional ability. The exam portion covers some basics, such as visual acuity, height, weight, blood pressure, and BMI.
Something included in these visits that’s perhaps not included in regular exams is end-of-life planning. Discussed only with the patient’s consent, this portion discusses life support and other sensitive healthcare decisions.
Thompson says providers can miss out on opportunities to insert the beneficial and revenue-building prevention visit into regular visits. And since it does not clash with office visit revenue, physicians should not hesitate to take advantage of this option. “Don’t delay,” Thompson says. “Because if you wait, the patient might go to another physician who performs the exam instead. So take advantage of this while you can. When patients call to schedule any appointment, check their eligibility to see if they’ve just joined a Medicare Part B plan.”
After patients have been active in Medicare Part B for more than a year, they become eligible for the Initial Wellness Exam. “It’s a little bit different than the Welcome to Medicare Visit,” Thompson says. “It requires the physician to establish a written screening schedule for the next five to ten years.”
Like with the Welcome visit, physicians can amend the regular office visit with the code for this exam, G0438, now reaping two office reimbursements in one time slot. The Initial Wellness Exam reimbursement runs to $159.02, a bit higher than the Welcome Visit. “It’s probably higher because of having to provide the five-year plan,” Thompson says.
For every year after, physicians can perform the Subsequent Annual Wellness Visit. That code, G0439, equates to a $106.13 reimbursement.
“You can also charge for the exam when a patient is coming in for something else,” Thompson says. “Because typically at this age, they’re on a schedule to come in every three months to follow up on something like diabetes or hypertension.”
Thompson suggests setting up profiles in the practice’s EHR (electronic health records) for all three of the preventive exams to make sure physicians check off every requirement. And, if possible, add in alerts to physicians to code for other counseling sessions that regularly crop up in exams.
“You can get payment if you’re doing tobacco cessation counseling,” Thompson says, adding that this isn’t just for Medicare, but many HMOs cover this too. If the physician spends three to ten minutes on the issue, a code G0436 results in a $13.50 reimbursement. That amount increases with more time, but practices must use the appropriate code for each time interval. “I think a lot of physicians do this, but didn’t know they could bill a separate code for it,” she says.
A similar option holds for diabetes self-management training that lasts at least 30 minutes. “Many times, when you’re with a patient who has just been diagnosed with diabetes, you can code for G0108 and the reimbursement is $50.27,” Thompson says. Medicare and HMOs allow coverage for that code annually.
On obesity counseling, the time requirement drops to 15 minutes, resulting in an allowable reimbursement amount of $24.60 under code G0447. “But they have to be BMI of 30 or higher. You can’t have a BMI of 29 and include this,” Thompson says.
Other codes include an annual depression screening for 15 minutes under code G0444 for a $16.44 reimbursement. 15 minutes on cardiovascular health (intense behavioral counseling therapy to reduce cardiovascular disease) nets a $24.60 reimbursement. Counseling to prevent sexually transmitted infections for at least 20 minutes results in a $25.55 reimbursement.
“But be careful,” Thompson says. “You can’t bill for many of these in addition to the Medicare annual wellness exams, because they’re already being covered in those visits.”
Only a primary care physician or practitioner can perform most of these exams, leaving practices such as urgent care or specialists, like ENTs, exempt. “Primary care physicians need these extra incentives, because they’re seeing a heavier patient load and not seeing the revenue from procedure incentives of the specialists.
“It’s important to look at the requirements,” Thompson says. And she warns providers to be diligent about noting down the amount of time spent with the patient on that code. “With any of these codes, the last thing you want to do is bill these out and not have the documentation.”