Q: Do insurance companies pay for wellness care?
A: Yes, some carriers pay for wellness exams and preventive medicine services. Here are the codes and descriptions:
Preventive Medicine Services—New Patient:
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling or anticipatory guidance or risk-factor reduction interventions, and the ordering of laboratory or diagnostic procedures, new patient:
- 99381: infant (age younger than one year)
- 99382: early childhood age (age one through four years)
- 99383: late childhood age (age five through 11 years)
- 99384: adolescent age (age 12 through 17 years)
- 99385: 18–39 years
- 99386: 40–64 years
- 99387: 65 years and over
Preventive Medicine Services— Established Patient:
Periodic comprehensive preventive medicine re- evaluation and management of an individual including an age- and gender- appropriate history, examination, counseling or anticipatory guidance or risk-factor reduction interventions, and the ordering of laboratory or diagnostic procedures, established patient:
- 99391: infant (age younger than one year)
- 99392: early childhood age (age one through four years)
- 99393: late childhood age (age five through 11 years)
- 99394: adolescent age (age 12 through 17 years)
- 99395: 18–39 years
- 99396: 40–64 years
- 99397: 65 years and over
Codes 99381-99397 are covered by most insurance plans when performed by an MD or DO. These codes are not covered by Medicare.
Initial preventive physical examinations (IPPE)—aka the “Welcome to Medicare” visit:
Use the Healthcare Common Procedure Coding System (HCPCS) code G0402. This is a “once-in-a- lifetime” covered Medicare benefit. It does not include lab tests. Co-pay, co- insurance, and deductible are waived.
G0402: Initial preventive physical examination: face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment.
Medicare annual wellness visits (AWVs):
Use HCPCS code G0438 for the initial AWV. This service is covered one time in the second year of eligibility. It does not include lab tests. Co-pay, co-insurance, and deductible are waived.
G0438: Annual wellness visit: includes a personalized prevention plan of service (PPS); initial visit. Use HCPCS code G0439 for the subsequent AWV. This service is covered one year after the initial AWV. It does not include lab tests. Co-pay, co-insurance, and deductible are waived.
G0439: Annual wellness visit: includes a personalized prevention plan of service (PPS); subsequent visit. A common diagnosis for wellness examinations, preventive medicine services, IPPEs, and AWVs is Z00.00.
This ICD-10 code is used for an encounter for a general adult medical examination without abnormal findings.
For wellness and maintenance chiropractic adjustments (non-Medicare), consider using HCPCS code S8990.
This HCPCS code is used for a manipulative therapy performed for maintenance rather than restoration. As a reminder, the only Medicare- covered service when performed by a chiropractor is spinal manipulation (CPT codes 98940, 98941, and 98942).
Additional prevention and wellness services and screenings that waive co- pays, co-insurance, and deductibles include:
- Bone mass measurements
- Smoking cessation counseling
- Diabetes screenings
- Glaucoma screenings
- HBV, HIV, and STD screenings
- Prostate cancer screenings
- Mammography and pap smear tests
- Abdominal aortic aneurysm ultrasound screenings
Chiropractic spinal manipulation for maintenance therapy is not payable by Medicare. According to Medicare, maintenance therapy includes services that seek to prevent disease, promote health, and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition.
When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive, the treatment is then considered maintenance therapy.
Marty Kotlar, DC, CPCo, CBCS, is president of target Coding. Kotlar is certified in CPt coding and healthcare compliance and has been helping chiropractors nationwide with billing, compliance, coding, and documentation for over 10 years. He can be reached at 800-270-7044, firstname.lastname@example.org, or through targetcoding.com.