Medicare Wellness Exam and ICD-10 Code | Practice Fusion

For as long as the Medicare program has been in existence, coverage for wellness and preventive-care examination have not been part of the traditional benefit. Fee-for-service Medicare had focused on illness-care and chronic disease management. Much of its budget was spent in hospital care, as measured by “hospital bed-days per thousand” which has historically been about 10 times higher than bed-days for commercially-insured (younger) patients.

However, over the past several years, things have started to change. With the introduction of Medicare Part D, drug coverage became a part of the standard Medicare benefit – no longer was it necessary to purchase additional insurance to cover medications. Medicare Advantage moved enrollees into an HMO model, and up until the past few years this was the only way that Medicare beneficiaries had access to wellness and prevention services.

As part of the 2003 Medicare Modernization Act (MMA), a new expansion of benefits occurred which covered initial preventive physical examination – the “Welcome to Medicare Visit.” This visit, well-intentioned, had its limitations: (1) it was a one-time-ever visit, and (2) had to be performed within the first 12 months of Medicare coverage. As a result, its uptake has been limited.

The Welcome to Medicare Visit
The Welcome to Medicare Visit is a comprehensive examination consisting of 7 components: (1) review medical and social history with attention to modifiable risk factors, (2) review potential risk factors for depression, (3) review functional ability and level of safety, (4) include height, weight, blood pressure, visual acuity and BMI, (5) conduct end-of-life planning (a new requirement in 2009), (6) education, counseling and referral based on the results of findings of the above 5 services, (7) education and a brief written plan such as a checklist for ongoing screening and prevention.

Coding for these services (for billing) is unique to Medicare. Though the diagnosis code (ICD-9 code) for the exam is V70.0 (general physical exam), the CPT code for the visit is not the wellness-exam code range used by every other insurance plan – the 99381-99397 codes. Instead, it is billed with a Medicare-only code, G0402 for the initial Welcome To Medicare exam. (Click for updated information regarding ICD-10 codes)

New Medicare annual wellness exams
This year, preventive services for fee-for-service Medicare beneficiaries has been expanded further, as part of the 2010 Patient Protection and Affordable Care Act (ACA). Now, in addition to the once-ever Welcome to Medicare visit availability in the first 12 months of Medicare enrollment, beneficiaries can receive an annual wellness and prevention exam with no copay (i.e. free) to the beneficiary.

The documentation requirements for these annual exams are the same as for the Welcome to Medicare Visit, noted above. Again, billing is not done using the normal wellness-exam CPT codes (99381-99397) – such claims will be rejected by Medicare as “non-covered services” – but instead one uses new, Medicare-only codes: G0438 for initial visits, and G0439 for subsequent visits. These codes became effective January 1, 2011. The new code (G0438) has 4.74 Relative Value Units, for a national payment average of $159.25.

New Practice Fusion templates
At Practice Fusion, we have received numerous requests to include templates for these exams in our Template Library. Thanks to great work from our user community, we have collected some great templates to assist in documenting these exams – these templates (like many of the templates in our library) arose “in the field,” created by physicians who had built something for their own use, and wanted to share them publicly.

We now have two new templates in our library: (1) MedicareIntroExam, and (2) MedicareAnnualWellnessExam. These templates will be included in the default-loaded templates for all new users, and can be searched from the library (search for “medicare”) by anyone who is a current user. Of course, as is the case with all our templates, they can be modified as-desired by local users to fit their own particular needs and preferences.

We extend our sincere thank-you’s to our user community who created these templates, and asked us to share them broadly. We hope that this will facilitate documentation for physicians who wish to take advantage of the newly-extended coverage available to Medicare beneficiaries this year.

Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR