The Ultimate Guide to Understanding and Getting Paid for Preventive Services

Chapter 3: Coding and Billing Preventive Services

Top Things to Know About the Preventive Services Medicare Covers

For practices seeking to expand their offerings, the following information is essential for understanding the preventive services Medicare covers.

Breakdown of Preventive Services Medicare Covers

Per Medicare guidelines, practitioners should work with their Medicare patients to determine whether these patients should receive the preventive services and screenings listed below. Most of these services are reimbursable to the rendering practitioner and usually fully covered by Medicare with no out-of-pocket expense to the patient.

They can be broken down as follows:

Assessments and Counseling

• Alcohol Misuse Screening: Medicare covers one screening annually and up to four brief, face-to-face counseling sessions per year.

• Depression Screening: Covered once annually by Medicare.

• Obesity Screening and Counseling: Intensive behavioral therapy is covered for patients with a body mass index of 30 or more.

• Behavioral Therapy for Cardiovascular Disease: A risk reduction visit is covered once annually by Medicare.

• Smoking and Tobacco Use Cessation Counseling: Medicare covers up to eight face-to-face visits every 12-month period.

• Low dose lung cancer screenings (LDCT) counseling to determine if LDCT imaging should be ordered

Clinical Procedures and Imaging

• Abdominal Aortic Aneurysm Screening: Covered by Medicare once in a lifetime.

• Bone Mass Measurements: Covered by Medicare for at-risk individuals once every 24 months.

• Lung Cancer Screening: A low dose computed tomography (LDCT) scan is covered once every 12 months for patients meeting predefined criteria.

Laboratory Diagnostics

• Cardiovascular Disease Screening: Covered once every five years and includes tests for cholesterol, lipid, and triglyceride levels.

• Diabetes Screening: Medicare covers up to two screenings per year for at-risk patients.

• Prostate Cancer Screening: All men over the age of 50 are covered once every 12 months.

Vaccinations

• Flu Vaccine: Covered once each flu season.

• Pneumococcal Shots: Medicare covers the initial vaccine, and the second shot is covered 11 months after the first vaccine is given.

• Hepatitis B Shots: Patients with medium to high risk for Hepatitis B are covered.

Role of the Medicare Annual Wellness Visit

As mentioned earlier, the Medicare annual wellness visit (AWV) is an annual appointment during which a patient meets with a clinical staff member to develop or update a personalized prevention plan. This plan is based on a patient’s current health and risk factors, with the goal of preventing disease. Not only does the AWV offer opportunities for the provision of preventive services, but it also allows for the creation of a future schedule of preventive services.

Coverage of Medicare Preventive Services

Medicare Part B covers many preventive services in full, meaning Medicare beneficiaries will not incur out-of-pocket expenses (co-payment or deductible) when they receive the services. Fully covered preventive services include those listed above as well as diabetes screening (up to twice per year for those patients at high risk of diabetes) and hepatitis C screening test (for those patients at high risk). Some preventive services that are likely to require cost-sharing by the beneficiary include a diagnostic mammogram, digital rectal exam for prostate cancer, and glaucoma test.

If patients seek treatment from providers who do not accept the preventive services assignment and/or if they are enrolled in a Medicare health plan or have other insurance, they may pay more out of pocket. Patients will also pay more if they exceed the covered frequency of a preventive service.

Reimbursement for Preventive Services from Medicare

It is worth noting again the financial value for providing organizations that offer the Medicare AWV. As of 2022, practices receive around $170 per initial AWV and $133 per subsequent AWV. When the necessary preventive services are provided at the same time as the AWV, that number increases.

Even when looking at the frequency of eligibility conservatively, Medicare patients who receive a full suite of preventive services could drive up practice revenue by more than $360 annually per patient. If 50 patients receive the full suite, practices could see $18,000 in annual reimbursement. In addition, with many patients, these services can be provided during just one AWV.

Below is a breakdown of the 2022 average reimbursement for a few preventive services commonly performed with the Medicare AWV, per the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule:

Note: Figures are rounded to nearest dollar amount based on national averages.

Avoiding Denials for Preventive Services

To verify patient eligibility for preventive services, practices must determine the last date that their patients received such services. Practices have two options for verification of this information:

• Automated verification via the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System, also known as HETS. To avoid purchasing costly tools needed to meet access requirements, many practices work with a vendor that supports electronic eligibility transactions and office automation.
• Manual verification, which is typically completed via phone call, clearinghouse, or Medicare administrative contractor (MAC) portal but is more time-consuming than automated verification.

Process for Preventive Services to Be Chosen as Medicare Benefits

Due to its regulatory and statutory authority, CMS can add coverage through the National Coverage Determination process if the service meets the following criteria:

1. Reasonable and necessary for the prevention or early detection of illness or disability;
2. Recommended with a grade of A or B by the U.S. Preventive Services Task Force; and
3. Appropriate for individuals entitled to benefits under Part A or enrolled under Medicare Part B.

Private insurers typically follow Medicare’s lead when new services are added. In fact, private payers are legally required to cover many services that USPSTF deems beneficial.

Helping Patients Stay on Track

Keeping track of what services need to be scheduled can be daunting for patients, especially when the timing of one preventive service is different than another (e.g., monthly rather than annually).

Technological tools can provide electronic reminders, and Medicare’s downloadable “Are You Up-To-Date on Your Preventive Services?” checklist is a helpful resource for patients.

List of ACA Preventive Services and Their CPT & HCPCS Codes

Background on ACA and Preventive Services

When the Affordable Care Act took effect in 2010, it expanded access to preventive care for millions of Americans by mandating that all non-grandfathered health plans cover preventive services for their members as long as those services are provided at the requisite time by an in-network practitioner. Initially, some payers were concerned about the financial impacts to their business. Ultimately, the significant cost savings for insurers and the entire healthcare system has encouraged them to come around and recognize the importance of preventive services for the American public.

What Preventive Services Are Covered Under the ACA?

Following are ACA preventive services, corresponding current procedural terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes and descriptions, as well as patient eligibility. Since services may be added by USPSTF as it continues to review the latest medical research, this list can change.

Abdominal Aortic Aneurysm Screening

• HCPCS G0389 — Ultrasound b-scan and/or real time with image documentation; for abdominal aortic aneurysm (aaa) screening

• Eligibility: Men aged 65 to 75 who previously or currently smoke. This screening is covered once per lifetime.

Alcohol Misuse Screening and Counseling

• HCPCS G0442 — Annual alcohol misuse screening, 15 minutes

• HCPCS G0443 — Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

• Eligibility: All patients are eligible for an annual screening, with four additional brief face-face counseling sessions per year for patients who screen positive for alcohol misuse.

Aspirin Use

• HCPCS G8598 — Aspirin or another antiplatelet therapy used

• Eligibility: Aspirin is used in high cardiovascular risk adults aged 50 to 59 to prevent cardiovascular disease and colorectal cancer.

Blood Pressure Screening, Cardiovascular Disease Screening, Cholesterol Screening and Statin Preventive Medications

• CPT 80061 — Lipid panel (must include CPT 82465 cholesterol, serum total; CPT 83718 lipoprotein, direct measurement, high density cholesterol; and CPT 84478 triglycerides)

• Eligibility: Adults of higher cardiovascular risk. Medicare specifically covers a cholesterol screening once every 5 years and, in addition to cholesterol screening, the services also include testing for lipid and triglyceride levels. All patients are eligible to receive blood pressure screenings.

Colorectal Cancer Screening

A list of CPT and HCPCS codes with descriptions and patient qualifiers can be found here.

• Eligibility: Specifically, for Medicare patients, colorectal cancer screening can be performed in a few different ways with each having its own qualifiers based on risk.

• For screenings using the multitarget stool DNA test, patients must be between the ages of 50 and 85, be asymptomatic, and at an average risk of developing colorectal cancer. Patients are eligible for this screening once every three years.

• Screening Flexible Sigmoidoscopy: Once every 48 months

• Colonoscopy: Once ever 10 years or 48 months after a previous sigmoidoscopy. For high-risk patients, colonoscopy is covered once every 24 months.

• Fecal Occult Blood Tests (FOBTs): Once every 12 months

• Screening Barium Enemas: Once every 12 months

Depression Screening

• HCPCS G0444 — Annual depression screening, 15 minutes

• Eligibility: ACA mandated that insurance plans must cover a screening for depression. For Medicare beneficiaries, depression screening is covered once annually.

Diabetes Screening

• CPT 82947 — Glucose; quantitative, blood (except reagent strip)

• CPT 82950 — Glucose; post glucose dose (includes glucose)

• CPT 82951 — Glucose; tolerance test (GTT), 3 specimens (includes glucose)

• Eligibility: This screening is for patients with certain diabetes risk factors or a diagnosis of pre-diabetes. Patients with pre-diabetes are eligible for a screening once every 6 months and once every 12 months for everyone else.

Falls Prevention

• HCPCS G0402/G0438/G0439 as part of Medicare’s initial or AWV.

• Eligibility: ACA mandated no-cost coverage for adults 65 years old and over who live in a community setting. Fall prevention is often discussed during Medicare’s annual wellness visit.

Hepatitis B Screening

• HCPCS G0499 — Hepatitis B screening in non-pregnant, high-risk individual includes hepatitis B surface antigen (hbsag) followed by a neutralizing confirmatory test for initially reactive results, and antibodies to hbsag (anti-hbs) and hepatitis B core antigen (anti-hbc)

• Other codes may apply for pregnant women.

• Eligibility: ACA ensured that this screening is covered for people who are considered high risk and for people who are from countries with high rates of hepatitis B prevalence. Patients are also eligible for screening if they were born in the United States and not vaccinated as an infant with one parent from a region with a hepatitis B prevalence rate of at least 8%. Medicare covers hepatitis screenings for both pregnant and non-pregnant women as well as asymptomatic adolescents and adults at high risk for hepatitis B infection.

Hepatitis C Screening

• HCPCS G0472 — Hepatitis C antibody screening, for individual at high risk and other covered indication(s)

• Eligibility: Patients who had a blood transfusion prior to 1992 and adults who were born between 1945 and 1965 are eligible for screening once per lifetime and annually for high-risk patients.

HIV Screening

• HCPCS G0432 — Infectious agent antibody detection by enzyme immunoassay (eia) technique, HIV-1 and/or HIV-2 screening.

• HCPCS G0433 — Infectious agent antibody detection by enzyme-linked immunosorbent assay (elisa) technique, HIV-1 and/or HIV-2, screening.

• HCPCS G0435 — Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2 screening.

• HCPCS G0475 — HIV antigen/antibody, combination assay, screening.

• Eligibility: This screening is for everyone ages 15 to 65 and can be performed annually. All other ages are eligible for patients who have increased risk factors. There are several codes relevant to their HIV screening.

Immunizations

• CPT 90670 — Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use.

• CPT 90732 — Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use.

• HCPCS G0009 — Administration of pneumococcal vaccine

• A list of CPT and HCPCS codes and their specific descriptions for the influenza vaccine can be found here.

• Eligibility: ACA mandated provisions for all recommended vaccines for both adults and children. Patients with Medicare Part B are encouraged to receive a pneumococcal vaccine and an annual influenza vaccine. The pneumococcal vaccine eligibility is subject to Medicare criteria.

Intensive Behavioral Therapy for Cardiovascular Disease (CVD)

• HCPCS G0446 — Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes.

• Eligibility: All adults once per year.

Lung Cancer CT Counseling and Screening

• HCPCS G0296 — Counseling visit to discuss need for lung cancer screening using low dose CT scan (LDCT)

• HCPCS G0297 — Low dose CT scan (LDCT) for lung cancer screening

• Eligibility: ACA mandated that high-risk adults who currently or previously smoked within the last 15 years and are between the ages 55 and 80 years old are eligible to receive a lung cancer screening. Medicare beneficiaries may receive a lung cancer screening if they are asymptomatic; have a tobacco use history of at least one pack per day over a 30-year period; are a current smoker; or quit within the last 15 years.

Medical Nutrition Therapy (MNT)

• CPT 97802 — Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes

• CPT 97803 — Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes

• Eligibility: For adults with diabetes, renal disease or who have had a kidney transplant

Obesity Screening and Counseling

• HCPCS G0447 — Face-to-face behavioral counseling for obesity, 15 minutes

• HCPCS G0473 — Face-to-face behavioral counseling for obesity, group (2-1), 30 min

• Eligibility: Payers must provide coverage for obesity screening and counseling for all members. Medicare beneficiaries who have a BMI greater than 30, are competent and alert, and see a qualified practitioner or primary care provider are eligible to receive up to 22 obesity counseling visits in a 12-month period. Visits taper over time. A list of Medicare coverage rules can be found here.

Sexually Transmitted Infection Prevention Counseling

• A list of sexually transmitted infection CPT and HCPCS codes can be found here.

• Eligibility: ACA expanded coverage for all adults at high risk of contracting a sexually transmitted disease.

Syphilis Screenings

• CPT 86592 — Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)

• CPT 86593 — Syphilis test, non-treponemal antibody, quantitative

• CPT 86780 — Antibody; treponemal pallidum

• Eligibility: All at-risk adults are eligible to receive screenings for syphilis.

Tobacco Use Screening

• CPT 99406 — Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

• CPT 99407 — Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

• Eligibility: All adult tobacco users are eligible for screening and cessation interventions regardless of tobacco-related disease symptoms. Per Medicare, patients must be alert and competent and consequent counseling must be performed by a qualified practitioner.

Tuberculosis Screening

• CPT 86580 — Skin test, tuberculosis, intradermal

• Eligibility: This screening service is covered for adults meeting certain criteria and are without symptoms or are at a high risk of contracting tuberculosis.

Billing for a Medicare Annual Wellness Visit: HCPCS Codes G0438, G0439, and G0402

The American Medical Association has estimated that about 5% of claims lines are denied by Medicare. Denials can lead to increased days in accounts receivable (A/R), write-off rates, and overall cost to collect, among other headaches for providing organizations. To better ensure that your annual wellness visit (AWV) claims are not denied, proper coding is essential. Not only does accurate coding ensure that practices receive proper reimbursements, but it also protects against penalties incurred from failed coding audits.

What is G0438?

G0438 is the HCPCS code that should be used for a patient’s first annual wellness visit. Its long descriptor is “Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit,” while its short descriptor is “Annual wellness first.”

Two key things to know about G0438:

1. It can only be used for a Medicare beneficiary who is no longer within the first 12 months after the effective date of their Part B coverage; and
2. It can only be used for a Medicare beneficiary if they have not already received either an initial preventive physician examination or an AWV within the past 12 months.

Medicare pays for a single initial AWV per beneficiary per lifetime.

What is G0439?

G0439 is the HCPCS code that should be utilized for all subsequent annual wellness visits. Its long descriptor is “Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit,” while its short descriptor is “Annual wellness subseq.”

That said, keep mind that if a practice takes on a new Medicare beneficiary and is providing that patient their first annual wellness visit, practitioners must determine if the beneficiary had an initial AWV provided by another organization. If so, the G0439 code would be used, not G0438 since G0438 was already billed by the other organization that provided the AWV service.

What is G0402?

Broadly speaking, IPPE, also known as the “Welcome to Medicare Visit,” takes place when a practitioner reviews a Medicare beneficiary’s medical and social health history as well as offers education on preventive services. Medicare pays for a single beneficiary IPPE per lifetime that must furnished no later than the first 12 months after the beneficiary’s eligibility date for Medicare Part B benefits.

G0402 is the HCPCS code that should be used for the IPPE. Its long descriptor is “Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment,” while its short descriptor is “Initial preventive exam.”

Additional Codes

Beyond the primary visit codes — HCPCS G0402, HCPCS G0438, and HCPCS G0439 — practitioners may use other codes to bill for services performed during a Welcome to Medicare Visit or AWV. If those additional codes are used, practitioners must include a note that supports the need for each service provided.

Many of these codes have guidelines that require them only to be used with specific visits after meeting certain criteria. For example, HCPCS G0444, used for a 15-minute annual depression screening, can only be added to subsequent wellness visits that are billed under G0439. If that specific code is used with the IPPE or initial AWV, it will be rejected. An abdominal aortic aneurysm (AAA) screening, coded as G0389, can only be provided with the IPPE code G0402 because it is ineligible to be used during AWVs.

Advance care planning (CPT 99497) is considered an optional element of the AWV but is considered a preventive service (and thus has its co-pay waived) when billed on the same day as an AWV with modifier -33.

HCPCS G0442 and HCPCS G0443 are additional codes that must be used in conjunction with each other to be valid. HCPCS G0442 is used for an annual alcohol screening, which should take approximately 15 minutes. G0443 is for 15-minute sessions of alcohol counseling. According to the Centers for Medicare & Medicaid Services, the screening service is required to occur prior to approval for a G0442. Thus, if a practitioner uses G0443 and no claims have been filed for G0442 in the preceding 12 months, the screening code will be denied.

Fifteen-minute obesity counseling sessions may be billed in conjunction with IPPE visits or AWV using HCPCS G0447. When wellness visits last longer than what is typical, prolonged preventive service codes designate a visit takes 30 minutes (G0513) or 60-plus minutes (G0514) past the typical duration of the service.

HCPCS G0438 and G0439: Coding Tips and Mistakes to Avoid

Using similar but different codes can be confusing. Since each visit requires different resources, they must be reimbursed at different rates. For example, during the initial AWV, the practitioner gathers all the patient information that becomes the basis for each subsequent AWV. Thus, as of 2022, the HCPCS G0438 code is reimbursed at a rate more than 30% higher than G0439. If a providing organization regularly neglects to select the G0438 code for an initial Medicare AWV and uses G0439 instead, the practice could lose a great deal of revenue.

Common Misuses of G0438 and G0439

If HCPCS codes G0438 or G0439 are not applied correctly, a denial will likely be triggered. Here are a few typical ways that practices incorrectly code annual wellness visits:

1. If a practice submits G0438 for a Medicare beneficiary for whom a claim with code G0438 has already been paid, the claim will be denied with a claim adjus tment reason code (CARC) of 149 (“Lifetime benefit maximum has been reached for the service/benefit category.”) and a remittance advice remarks code (RARC) of N117 (“This service is paid only once in a patient’s lifetime.”).
    
2. If a practice submits a claim for a G0438 or G0439 within the first 12 months after the effective date of the beneficiary’s first Medicare Part B coverage, it will be denied as that beneficiary is eligible for the IPPE. Such claims will be denied with a CARC of 26 (“Expenses incurred prior to coverage.”) and a RARC of N130 (“Consult plan benefit documents/guidelines for information about restrictions for this service.”).
    
3. Do not bill G0438 or G0439 within 12 months of a previous billing of a G0402 (initial preventive physician examination), G0438, or G0439 for the same beneficiary. These subsequent claims will be denied with a C ARC of 119 (“Benefit maximum for this time period or occurrence has been reached.”) and the aforementioned N130 RARC.
    

Note: Patients are eligible to receive Medicare annual services again on the first of the month they are performed in, one year later. For example, if a patient has an AWV on Nov. 20, 2022, they are eligible again on Nov. 1, 2023.

Additional Annual Wellness Visit Coding Tips

When patients receive their AWV, it is often accompanied by one or more evaluation and management (E&M) services. If what the patient receives can be defined as a “significant, separately identifiable medically necessary E&M service” in addition to the annual wellness visit, CPT codes 99201-99215 may be reported. Along with HCPCS code G0438 or G0439, modifier -25 must be appended to the medically necessary E&M service. CPT guidelines define the -25 modifier as “Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”

Before coding and billing for one or more E&M services, first determine whether some of the components of the medically necessary E&M service, such as a portion of the history exam, were part of the annual wellness visit. If so, these components should not be included when determining the most appropriate level of the billable E&M service.

The HCPCS code G0468 often pops up in resources that describe coding and billing for annual wellness visits. Unless a practitioner works in a federally qualified health center (FQHC), this HCPCS code would not apply. Why? G0468 is solely used by FQHCs to code and bill for AWVs and IPPEs. Its long descriptor is “Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV,” while its short descriptor is “FQHC visit, IPPE or AWV.”

Finally, keep in mind that during the annual wellness visit, many Medicare Part B preventive services may be provided as optional elements, including advance care planning, depression screening, alcohol misuse screen and counseling, and counseling to prevent tobacco use.

Staying Up to Date with AWV Coding Requirements

Occasionally, codes and coding requirements for the annual wellness visit change, so to help avoid being audited because of coding noncompliance, organizations providing AWVs must stay current. Implementing a software solution provided by a vendor that makes maintaining compliance a top priority can help organizations better ensure they code and bill using current rules, thus decreasing the risk of noncompliance and denials, and increasing the likelihood of proper payments.