Medicare Annual Wellness Visit

[harllee]

Medicare totally denied the $400 bill and said it was not coded properly. No deductible involved since I had already meet the deductible for the year (2017). Medicare said it needed to be resubmitted with the correct code for annual wellness exam, but the billing department says it will not resubmit with that code. I figure the billing department will not resubmit with the correct code because they know Medicare will only pay $150 or so and they want to get the full $400 from me.

 

[Bram]

I believe in my dr’s office the dr is the one who actually codes the visit, as he simply ticks off a box that has all the options for type of care rendered along with its applicable code #. And I’ve had billers say to me that they aren’t authorized to change a code, it must go thru the dr. to make any changes.

I suggest you speak to the practice (office) manager & voice your concerns. Start there, then ramp up if you don’t get satisfaction, & discuss it with dr. You can also appeal the Medicare denial, if you get nowhere with those steps. How to appeal a decision would be on the website &/or Medicare EOB.
I wouldn’t throw out the fraud threat early on.

 

[MBSC]

Did Medicare actually DENY the claim for $400? For what reason?
...it seems that they should’ve paid something on a claim coded “99397, preventative medicine exam”? I would have thought Medicare would’ve paid 80% of the approved amount, after deductible met.

It is denied by Medicare because it is a non-covered service. Medicare coverage of preventive services is limited.

A full physical exam, 99397, is different than an Annual Wellness Visit, G0438/G0439, or “Welcome to Medicare Exam”, G0402. A full physical 99397 or 99387 is NOT covered by Medicare and patients are responsible for the cost and can be billed. There is no fraud or ignorance here but there was a failure in communication from the doctor’s office.

Lastly, we come to the Comprehensive Preventative Medicine Exam. Patients and medical providers refer to this exam by such names as a routine physical, annual physical, annual exam, well exam, routine exam, full physical, annual routine physical, etc.

Regardless of what the exam is called, the CPT codes 99397 (established patient) and 99387 (new patient), which represent the preventive care examination, have very specific parameters and are never reimbursed by Medicare.

Additionally, billing the 99397 (not covered by Medicare) and billing the AWV at the same time is not fraudulent and can be billed if that is exactly what happened and the physician has the proper documentation.

Full Article: https://capturebilling.com/am-i-just-dealing-with-coding-department-that-is-ignorant/

 

[kaneohe]

https://capturebilling.com/am-i-just-dealing-with-coding-department-that-is-ignorant/

an interesting article on this subject..........sounds like the doctor (and patient) need to be schooled on this issue. I would put the burden on the doctor since he/she should be aware of the problems it causes for patients. Doctors deal with this everyday; the patient only once (till they get burned).

don't know this is the difference but my takeaway is that if you are fishing in the dark looking for possible problems, this is not covered.........but if you have a reason/symptom for looking, it should be covered?

 

[mpeirce]

So am I right in thinking "regular" medicare doesn't cover an annual "physical"? Huh.

 

[MichaelB]

So am I right in thinking "regular" medicare doesn't cover an annual "physical"? Huh.

Here’s a good overview of Medicare and annual physicals prepared by Cleveland Clinic https://my.clevelandclinic.org/ccf/media/files/Patients/medicare-faq-flyer.pdf

 

[harllee]

Here’s a good overview of Medicare and annual physicals prepared by Cleveland Clinic https://my.clevelandclinic.org/ccf/media/files/Patients/medicare-faq-flyer.pdf

Michael, OP here, thanks for the Article. Looking at the Article, what I got was the Annual Wellness exam, which is what I asked for. I did have some blood work done and it was billed separately and Medicare has already paid for that (I had already meet my annual deductible). If my doctor thinks he also did some treatment for me for my allergies, based on this Article that should have been billed separately. I definitely did not have a comprehensive physical.

If a patient specifically asks for the Medicare annual wellness exam, which I did, shouldn't there be some sort of disclosure that what they are getting is not going to be billed as a wellness exam? I feel like i was mislead.

 

[Gotadimple]

Michael, OP here, thanks for the Article. Looking at the Article, what I got was the Annual Wellness exam, which is what I asked for. I did have some blood work done and it was billed separately and Medicare has already paid for that (I had already meet my annual deductible). If my doctor thinks he also did some treatment for me for my allergies, based on this Article that should have been billed separately. I definitely did not have a comprehensive physical.

If a patient specifically asks for the Medicare annual wellness exam, which I did, shouldn't there be some sort of disclosure that what they are getting is not going to be billed as a wellness exam? I feel like i was mislead.

The Medicare Handbook tries to define the difference between a Wellness exam and an office visit, but it is hard to discern.

You need to contact the doctor and specifically state your issue about billing for a comprehensive exam, which you did not receive. He/She needs to confirm to Billing what was discussed from the chart notes, then they will make the change.

Does your doctor's office provide a place for you to see chart notes online? If so, you can read the notes and have additional detail to provide to the doctor. Bottomline: the Billing office goes on what is coded by the doctor and if it is incorrect they normally are not skilled at interpreting the doctor's chart notes, so he/she needs to tell them what should change.

- Rita

 

[MissMolly]

Does anybody, personally, find these Welcome to Medicare or Annual Wellness visits worthwhile? It sounds to me like a complete waste of time, but maybe I am not understanding something.

 

[Gotadimple]

You don't get much with either visit.

But, that said, my doctor's office has commented on their website that they find that most patients don't need more than the BP check and a refill on RX if everything else is OK. That is, if you are feeling fine and lab tests and other diagnostic tests are normal, there is no need for a comp exam because it adds cost where it is not warranted.

If you have issues to discuss, then, it's a good starting point for additional testing or diagnosis, IMO. You basic health is assessed, and anything further becomes an office visit (not a comprehensive physical).

 

[grasshopper]

Does anybody, personally, find these Welcome to Medicare or Annual Wellness visits worthwhile? It sounds to me like a complete waste of time, but maybe I am not understanding something.

I guess it depends on the practitioner, I get a lot more than AWV from my doc, but billed as one.

 

[H2ODude]

I'm not understanding how you can be billed $400 for a legitimate consultation. If you met the deductible, and assuming you have a medigap to complement your regular Medicare, other than copay depending on your medigap, how they bill that? Admit I'm new to M (almost 67) but once deductible paid we've just gotten hit with copays and some piddling little things that the state here allows them to goose you on for what M doesn't pay. For example I went in for cyst in foot, they needled it out, did ultrasound, and I don't recall all the absurd charges they sent to M, but in the end all I had was the copay for what looked like almost $1,000 charged to M. By the way, I think American healthcare "insurance" is absurd.

 

[Walt34]

Does anybody, personally, find these Welcome to Medicare or Annual Wellness visits worthwhile?

It depends on the person I suppose. I skip them myself because I'm in there about every three months or so with follow up on other issues so I think it would be redundant for me. If the patient doesn't go in more than once a year then I'd think it is worthwhile for anyone over 65, who probably should see a doc at least once a year.

 

[Silver]

https://capturebilling.com/am-i-just-dealing-with-coding-department-that-is-ignorant/

an interesting article on this subject..........sounds like the doctor (and patient) need to be schooled on this issue. I would put the burden on the doctor since he/she should be aware of the problems it causes for patients. Doctors deal with this everyday; the patient only once (till they get burned).

don't know this is the difference but my takeaway is that if you are fishing in the dark looking for possible problems, this is not covered.........but if you have a reason/symptom for looking, it should be covered?

I have had the exact same thing happen as did the OP. Before calling my PCP's office about the charge I did some research and found the article referenced by kaneohe. The article made it clear that the Medicare code 99397 is never covered by Medicare but available for use by physician practices, and should not be considered an error when used. Having worked in health care for 30 years I admit I am cynical, but I decided that the code was used when possible in order to boost practice revenue. The definitions of a patient visit are largely subjective unless specific testing was done and the results documented. In many cases, that leaves enough room to use this charge.

I called my PCP's billing office and challenged the code. They recoded the visit which was accepted and paid by Medicare. I got the sense that they were willing to change the code when challenged, but would use it as they thought they could. I imagine that this is common practice, with some practices being more flexible about the recoding than others.

 

[MichaelB]

If a patient specifically asks for the Medicare annual wellness exam, which I did, shouldn't there be some sort of disclosure that what they are getting is not going to be billed as a wellness exam? I feel like i was mislead.

harllee, you are your own best advocate, and your only advocate in this. This billing may have happened in error. It’s also possible that office often bills the most expensive codes, and some people pay. My suggestion would be to contact the office, ask for the manager, and clearly state you specifically requested and went in for a wellness exam and that’s what they need to bill to Medicare, and if the manager refuses, discuss it directly with the physician.

 

[harllee]

harllee, you are your own best advocate, and your only advocate in this. This billing may have happened in error. It’s also possible that office often bills the most expensive codes, and some people pay. My suggestion would be to contact the office, ask for the manager, and clearly state you specifically requested and went in for a wellness exam and that’s what they need to bill to Medicare, and if the manager refuses, discuss it directly with the physician.

Thanks, I have already talked to the billing department (very large practice, probably 50 doctors), they refused my first request to recode, I have asked to speak to a supervisor and I awaiting to hear back from that. If that does not work I will then talk to the doctor.

 

[harllee]

Does anybody, personally, find these Welcome to Medicare or Annual Wellness visits worthwhile? It sounds to me like a complete waste of time, but maybe I am not understanding something.

OP here, I have certainly learned my lesson and I will never go in an annual wellness visit again! I think it would be best to go in with some complaint (like I feel sick, tired or old) and as a part of that complaint ask for things that would normally be included in the annual exam like blood work, etc. Medicare will pay if you go in with a complaint once your deductible is satisfied.

 

[MissMolly]

OP here, I have certainly learned my lesson and I will never go in an annual wellness visit again! I think it would be best to go in with some complaint (like I feel sick, tired or old) and as a part of that complaint ask for things that would normally be included in the annual exam like blood work, etc. Medicare will pay if you go in with a complaint once your deductible is satisfied.

I think I have learned from your lesson. I doubt I will ever schedule one of these. I will be signing up for Medicare later this year.

 

[harllee]

I'm not understanding how you can be billed $400 for a legitimate consultation. If you met the deductible, and assuming you have a medigap to complement your regular Medicare, other than copay depending on your medigap, how they bill that? Admit I'm new to M (almost 67) but once deductible paid we've just gotten hit with copays and some piddling little things that the state here allows them to goose you on for what M doesn't pay. For example I went in for cyst in foot, they needled it out, did ultrasound, and I don't recall all the absurd charges they sent to M, but in the end all I had was the copay for what looked like almost $1,000 charged to M. By the way, I think American healthcare "insurance" is absurd.

OP here, I am new to Medicare too (age 66) and I am trying to figure it out. Medicare will not pay anything for an annual physical (neither will the medical supplement). Medicare supposedly pays for a mythical "annual wellness exam" but as I have found out, it is almost impossible to get one. What medicare pays for is for when you go to your doctor for a sickness or problem (like your toe or the flu or something). You would think Medicare would want people to get preventative things like an annual physical to prevent disease but it does not work that way.

 

[braumeister]

You would think Medicare would want people to get preventative things like an annual physical to prevent disease but it does not work that way.

You might just be missing the fact that the "annual wellness visit" is just that -- a visit that covers a few administrative things. It's not an exam, and not a physical. Just a visit that shouldn't take more than 5-10 minutes total. Worthless for nearly everyone.

Even if you had been billed properly for the AWV, you would have been dissatisfied.

 

[misanman]

When I have gone in for an annual exam, the office has me sign a document agreeing to pay costs not covered by Medicare. That said, I don't recall that the cost was excessive. Certainly not anywhere close to $400.

 

[HadEnuff]

OP here, I have certainly learned my lesson and I will never go in an annual wellness visit again! I think it would be best to go in with some complaint (like I feel sick, tired or old) and as a part of that complaint ask for things that would normally be included in the annual exam like blood work, etc. Medicare will pay if you go in with a complaint once your deductible is satisfied.

well, that answered my next question.

I take it then, that Medicare addresses symptom related issues. How about screening bloodwork, like the "routine" "full panel",,,often ordered at yearly physicals to screen for things like liver function, kidney function, hyperlipidemia(cholesterol et.al.), and PSA?

 

[harllee]

well, that answered my next question.

I take it then, that Medicare addresses symptom related issues. How about screening bloodwork, like the "routine" "full panel",,,often ordered at yearly physicals to screen for things like liver function, kidney function, hyperlipidemia(cholesterol et.al.), and PSA?

OP here, well that is the strange thing...Medicare paid for all my blood work, full panel, cholesterol, diabetes screening, etc. (no PSA I am female but it did pay for mammogram and pap smear) but medicare did not pay for the doctor to go over the lab results with me. Also paid for pneumonia shot.

 

[harllee]

You might just be missing the fact that the "annual wellness visit" is just that -- a visit that covers a few administrative things. It's not an exam, and not a physical. Just a visit that shouldn't take more than 5-10 minutes total. Worthless for nearly everyone.

Even if you had been billed properly for the AWV, you would have been dissatisfied.

OP here. But I was not informed that i would be charged for anything extra. if I had been told I could have made an informed consent. For $400 I would have thought I would have gotten much more than the 15 minutes i did. For $400 i would have expected a full exam which i definitely did not get. I guess I just need a new doctor.

 

[homestead]

There must be some differences in Medicare plans. Our BC Medicare Advantage covers annual wellness visit and in addition includes an annual physical exam. You may have to pay a copay if you also are treated for a new medical condition or monitored for an existing condition at the same time you are getting your physical.