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Medicare Physical or Yearly Wellness

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datwood:
Hello, I need your please.  When I submit a yearly physical on a Medicare patient I use the G0439 and yes we get paid for that, however, for 93000 they are not paying. Is there another G code for it so we can get paid for it? All your help to answer this question is very much appreciated.

Thank you,
D

RichardP:
Think about the difference between preventive / screening medicine and diagnostic medicine.

With diagnostic medicine, patient comes in with severe chest pain and/or shortness of breath.  Could be a heart issue.  An EKG might help diagnose what the problem is.  EKG is billed with appropriate diagnosis code (chest pain / shortness of breath / etc.)

With preventive / screening medicine, patient comes in for a yearly wellness checkup.  If patient is not complaining of severe chest pain and/or shortness of breath, an EKG is not needed to diagnose, because nothing is calling out to be diagnosed.  We are just getting an assessment of the patient's overall health status.  This is billed with a wellness visit code.

If a patient presents with with any issue that can realistically be heart-related, Medicare will pay for an EKG.  But payment depends on an appropriate diagnosis code - other than a wellness visit.  That is, Medicare will pay for EKGs that are diagnostic.

Medicare will pay for only one EKG that is preventative / screening - for the lifetime of the patient.  That would be during the Initial Preventive Physical Examination (IPPE) - also known as the Welcome to Medicare Preventive Visit.

Medicare will pay for one Annual Wellness Visit per year.  Generally, these are preventive / screening types of exams, not diagnostic.  Any diagnostic tests done as part of the Wellness Exam are considered part of the work that the Wellness Exam payment covers.  Medicare will pay for a diagnosis effort that includes an EKG only if it is coded as a separately-identifiable work event that is different from the Wellness Exam.  The EKG would need to be coded with a relevant diagnosis code and modifier, not with the Wellness Exam code.

Other than the once-in-a-lifetime occasion, Medicare will not pay separately for an EKG that is part of a wellness exam.

See the attached chart.

http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/downloads/MPS_QuickReferenceChart_1.pdf

datwood:
Thank you Richard =).

D

mtlopez:
EKG FOR MEDICARE YOU SHOULD USE G0403

RichardP:
mtlopez - open the link I provided in my previous post above.  Look at the top column heading, second from the left - it says HCPCS/CPT CODES.  You will find your code in the first box under that column heading.

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