Clearing up preventive visit confusion

March 5, 2020
Bill Dacey
Volume 97, Issue 3

Explaining what can and can't be done for an initial visit.

Q: I’m confused about the  various Medicare preventive visits. The Initial Preventive Physical Examination (IPPE) and annual wellness visit (AWV) list depression screening (G0444) & alcohol screening (G0442) in the CMS documents online, but doesn’t CMS forbid the use of these codes during welcome to Medicare and initial wellness visits?

A:  There are several documents on the CMS website outlining the IPPE and AWV service and the required components of those. Some just list all the potential “other Medicare Part B Preventive Services.” But you are correct about the G0444; that is bundled into both the G0402 and the G0438. 

You can bill G0444 with a G0439, the subsequent AWV, which does not list depression screening as a required element.

But none of the AWVs or the IPPE specifically name alcohol screening or counseling- and neither the G0442 or the G0443 is currently bundled with these codes, suggesting that they can be billed along with the G0402. G0438 and G0439. The IPPE does mention alcohol, tobacco and other drugs under “Review the patient’s history”, but that’s not the same as counseling.

However, the health risk assessment (HRA) that is required for the G0438 and G0439, includes a review of Psychosocial and Behavioral risks-which would surely include alcohol. And the questions in the standard HRA are enough to score a patient’s risk. If taken out of the HRA-and set up as a discrete screening section in the chart with some actual detail and, of course, time documented-this could support a G0442 in addition to any of these codes.

You would likely only do this with patients that scored positive, and not make this a routine part of IPPEs or AWVs.

Q: I was wondering if you could provide guidance on using time for coding when the time is 20 minutes since that is exactly between the 15 minute/99213 and the 25 minute 99214?  I am running into this quite often because they have changed most of my appointments to 20 minutes. 

I have been billing anything 20 minutes or less as 99213 and 21 minutes to 30 minutes as 99214.  If it is case by case based on insurance that the person has (which I do not have time to look up for every patient) then should I just use the lower time frame every time?A:
  It would appear that based on your comment about “insurance” that you are at least vaguely aware that governmental and commercial payers may do this differently.

The bad news is that Medicare has pretty clearly said that the “midpoint” rule (meaning more than halfway between two time listed as below qualifies you for the higher code) does not apply to evaluation and management (E/M) codes.

The AMA and the CPT manual do endorse the midpoint rule. Medicare specifically doesn’t for E/M codes.

At least for Medicare/Medicaid and TRICARE, if you are between two typical times you have to use the lower. For commercial payers you could go with the midpoint, i.e., 21 minutes being enough for a 99214.

But providers rarely have perfect knowledge of a patient’s insurance, so the safe play is to stick with 25 to 39 minutes for a 99214 based on time, for everyone.

This is changing for everyone in 2021. The AMA is redefining some time parameters for the office visit codes 99202-99215. This would appear to eliminate the ‘midpoint’ rule for commercial payers. So stay tuned.

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