Member Forum

1.  Medicare coding

Posted 01-16-2017 06:30
I have a fairly large Medicare population and am having issues with coding a 'well woman' exam. Since Medicare does not have preventative codes for this. Some references say us an E/M plus the G codes for pelvic/ CBE, and collection I'd Pap specimen. But when I tried this, the claim was sent back (by Athena - which we are in the process of dumping) saying the 99213 was not allowed. Ugh. What's the best way to get reimbursed for these visits?

I do promote the Medicare Annual Wellness Visits for my patients. Do you combine this with a physical?


Tracy Baum
Mountain Sage Family Clinic
Dubois, WY

2.  RE: Medicare coding

Posted 01-22-2017 22:36
You can use and should be reimbursed for -13 assuming you have ICD-10 to connect to it- i.e. whatever problem you discussed ( atrophic vaginitis or HTN or whatever). Then place -25 modifier on your -13 and use the G code for whatever part of prevention exam you did.

did you do this and not get paid? 

You can also do a Medicare wellness with its g code and then use another appropriate G code for the prevention exam portion.  I found out the hard way no -25 modifier here. If you place it you just won't get paid for that line.

Come to the March call, 1st Wednesday in March- what's that code?   You can ask all these questions or any other code questions and hear what others though the years have figured out.

i think Medicare and procedure coding hugely helpful to share tips. I just learned about proper vaccine coding and now get more than a hundred more dollars a visit because of it. So I'll be on the call. I always glean something most helpful. 

Melissa Weakland MD
Ballard Neighborhood Doctors
Seattle WA
IMP since 2007

3.  RE: Medicare coding

Posted 01-23-2017 04:35
There is a special G code for the PAP and pelvic.?? I think G0009 but I have to look that up.?? then the Q0091 for collection of PAP which they also pay for.?? Use a -33 modifier on anything that is "wellness".
--  Kathy Saradarian, MD Solo since 2003 Always Private, Small Group since 1990 Practice Partner since 2003 Branchville, NJ

4.  RE: Medicare coding

Posted 01-23-2017 09:45
I find pure Medicare fairly straight forward, re combining E/M codes with the AWV.      Like Melissa, I attach a -25 modifier to the E/M code.  No problem being reimbursed, except when it is only 364 days or less from last AWV.

I didn't think Medicare covered the G codes for pelvic exam at same time as AWV.  If others have found a way, I would like to hear it.    

Medicare Advantage plans are more problematic, since they seem to have their own rules.  

Mike Safran

5.  RE: Medicare coding

Posted 02-23-2017 17:54
This has been nagging at me and I finally made time to look- 

I've billed -13 with 25 modifier (paid 61.71)  then G0438 for annual wellness (paid 182.42)  then G0101 for pelvic (no modifier and paid 40.71) and Q0091 for pap (no modifier and paid 49.00)

so there it is - doable and paid.

I have discovered modifiers -25 ONLY on the -13 or -14 ; if put on anything else you don't get paid and I don't think a reason really given...

haven't been paid when for breast exam without pelvic.
And have to be very careful age or won't be covered.

Melissa Weakland MD
Ballard Neighborhood Doctors
Seattle WA
IMP since 2007

6.  RE: Medicare coding

Posted 02-24-2017 14:21
I'm responding here only because I just had a conversation about the 364 day issue with a partner, coder and receptionist about this last week.

A partner had an AWV on her schedule that was less than 365 days from the last.  She asked me if it could be done/paid for. I told her my understanding was it had to be 365 days or more from the last visit, so she chose to cancel the patient.  It was just minutes before the visit, so the patient may not have been happy.  Afterword, the receptionist said she had scheduled the patient because she was told that if it's within the same month as the visit a year ago it could be scheduled.  So that got me looking, and she is correct:

Page 6

"Medicare covers an AWV for all beneficiaries who are no longer within
12 months after the effective date of their first Medicare Part B coverage
period and who have not gotten either an IPPE or an AWV within the past
12 months (that is, at least 11 months have passed following the month in
which the IPPE or the last AWV was performed)."

So, for example, if they had an AWV Feb 24, 2016, you could next do an AWV Feb 1, 2017 or later.  Anybody ever tested this?

Jeff Huotari

7.  RE: Medicare coding

Posted 10 days ago
I was asked from our billing person about a medicare AWV I did recently on Sept 18 2017. Her  prior AWV was Sept 29 2016.

I remembered the conversation here, did a quick search and found Jeff's notes that this could be done in the same month or later as the prior AWV.  He asked- anyone test this out?

Well- I"m testing. Anyone have experience with this already?
Sure hope I get paid... this phrase seems to be our collective mantra  :)

If of interest to others I'll try to remember to post once payment posted.

Melissa Weakland MD
Ballard Neighborhood Doctors
Seattle WA
IMP since 2007

8.  RE: Medicare coding

Posted 10 days ago

Definitely would like to know the outcome.  I have been afraid to do AWV unless 366 days from prior.   I thought I had some "364 day" ones rejected, but cant be certain.

Michael S. MD

9.  RE: Medicare coding

Posted 7 days ago
Medicare annual wellness visit may be done any day of the month. So, if it was done Sept 29.2016, you can do another one after Sept 1 2017.
Hope this helps.

10.  RE: Medicare coding

Posted 01-23-2017 11:14
G0101 is the code for breast/pelvic exam
Q0091 is for the collection of the PAP
-33 is for any prevention service.

G0009 - is the code for pneumonia vaccine administration.  

Kathy Saradarian