Understand billing and coding for wellness care

Q: Do insurance companies pay for wellness care?

A: Yes, some carriers pay for wellness exams and preventive medicine services. Here are the key codes and descriptions:

1. Preventive medicine services—new patient

Initial comprehensive preventive medicine evaluation and management of an individual, including an age- and gender-appropriate history, examination, counseling, anticipatory guidance and risk-factor reduction interventions, and the ordering of laboratory and diagnostic procedures, for a new patient.

• 99381: Infant (ages younger than 1)
• 99382: Early childhood (ages 1–4)
• 99383: Late childhood (ages 5–11)
• 99384: Adolescent (ages 12–17)
• 99385: Ages 18–39
• 99386: Ages 40–64
• 99387: Ages 65 and over

2. 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, anticipatory guidance and risk-factor reduction interventions, and the ordering of laboratory and diagnostic procedures, for an established patient.

• 99391: Infant (ages younger than 1)
• 99392: Early childhood (ages 1–4)
• 99393: Late childhood (ages 5–11)
• 99394: Adolescent (ages 12–17)
• 99395: Ages 18–39
• 99396: Ages 40–64
• 99397: Ages 65 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.

3. 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 payments are waived.

G0402: Initial preventive physical examination; face-to-face visit, services limited to a new beneficiary during the first 12 months of Medicare enrollment.

4. Medicare Annual Wellness Visits (AWV)

• 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 payments are waived.
• G0438: Annual wellness visit; includes a personalized prevention plan of service (PPS); initial visit.
• Use HCPCS code G0439 for a subsequent AWV. This service is covered one year after the initial AWV. It does not include lab tests. Co-pay, co-insurance, and deductible payments 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 code is used for a manipulative therapy performed for maintenance rather than restoration of function. But bear in mind that 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 deductible payments include:

• Bone mass measurements
• Smoking cessation counseling
• Diabetes screenings
• Glaucoma screenings
• HPV, HIV, and STD screenings
• Prostate cancer screenings
• Mammogram and pap smear tests
• Abdominal aortic aneurysm ultrasound screenings

Chiropractic spinal manipulation for maintenance therapy is not payable by 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 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, is certified in healthcare compliance, and has been helping chiropractors nationwide with billing, compliance, coding, and documentation for more than 10 years. He can be reached at 800-270-7044, info@targetcoding.com, or through targetcoding.com.