Medicare Medical Billing Newsletter Has Important Information for Primary Care Physicians


As a Primary Care Physician you probably generate numerous claims for Annual Wellness Visits for your Medicare Beneficiaries. If you are an outpatient hospital/facility based provider, you need to be aware of the upcoming changes for the payment of HCPCS G0438 and G0439.


Under current claims reimbursement processes, a preventive service that has been submitted for both a “professional” service (the professional claim for the delivery of the service itself) and a “technical” service (the institutional claims for a facility fee)for the same day, payment is allowed for both. Review of this process has identified overpayments in some case and future recoupments will be initiated.

  To remedy this, new claims processing regulations become effective for claims processed on or after April 1, 2013 allowing payment for either the practitioner or the facility for furnishing the AWV.

This regulation in based on the fact that codes G0438 and G0439 have no separate payment for a facility fee. The claim will be posted to the Medicare beneficiary's utilization history and processed/reimbursed as the “professional” service only, regardless of whether it is paid on a professional claim or an institutional claim.

  Note: Only one payment for the AWV will be allowed on the same date and paid on the first claim received.

Recommendation: If you are performing AVW's in a facility, you should discuss these billing changes with them immediately. It is necessary to come to an amicable and mutally agreed upon approach to which entity will be submitting the claims for these services and how the reimbursement would be distributed to both parties. By planning ahead, you will be preventing any possible difficulties in your working relationship with the facility.