What is the billing level for a patient with Medicare who has abnormalities found during a routine wellness visit?

Billing for Medicare Wellness Visit with Abnormalities

When abnormalities are found during a Medicare Annual Wellness Visit that require significant evaluation and management beyond the scope of the wellness visit, you should bill both the wellness visit code (G0438 or G0439) AND a separate problem-oriented E/M code (99212-99215) with modifier 25 attached to the E/M code. 1

Primary Billing Approach

• Bill the wellness visit using the appropriate G-code: G0438 for initial wellness visits or G0439 for subsequent annual wellness visits, NOT the standard preventive care codes (99381-99397) which Medicare does not reimburse for wellness visits 1

• Add a separate E/M service when the visit becomes problem-focused: When abnormalities require significant evaluation beyond the wellness visit scope—meaning you're addressing specific problems with medical decision-making, not just screening—bill an appropriate E/M code (99212-99215) in addition to the wellness visit code 1

• Attach modifier 25 to the E/M code: This modifier indicates that the E/M service was a significant, separately identifiable service performed on the same day as the wellness visit 1

Determining the Appropriate E/M Level

The E/M code level (99212-99215) should be based on either total time spent or medical decision-making complexity, whichever yields the appropriate level of service 2:

Time-based coding thresholds for established patients:

• 99212: 10-19 minutes total time 2
• 99213: 20-29 minutes total time 2
• 99214: 30-39 minutes total time 2
• 99215: 40-54 minutes total time 2

Medical decision-making (MDM) complexity:

• To qualify for a specific MDM level, 2 out of 3 elements must be met: number/complexity of problems addressed, amount/complexity of data reviewed, and risk of complications 2
• An undiagnosed new problem with uncertain prognosis qualifies as moderate complexity, supporting 99214 coding 2
• Problems must be actively addressed during the encounter, not merely listed in the chart 2

Critical Documentation Requirements

For the wellness visit component:

• Document all required AWV elements including health risk assessment, personalized prevention planning, and cognitive screening 1

For the separate E/M service:

• Clearly document that the abnormality required significant, separately identifiable evaluation and management work beyond the wellness visit scope 1
• Include clear statements of problems addressed, risk assessment, and medical decision-making rationale 2
• If using time-based coding, document total face-to-face time with the patient 2
• Document the medical necessity for any additional diagnostic testing ordered 3

Common Pitfalls to Avoid

• Do not use outdated 2013 time thresholds: The 2021 guidelines significantly changed time requirements 2
• Do not upcode: Select the E/M level that is truly supported by your documentation—approximately 26% of E/M claims for Medicare patients are incorrectly upcoded 3
• Do not bundle laboratory tests into the E/M code: Bill laboratory tests separately using appropriate CPT codes 3
• Ensure the problem-focused work is truly separate: The abnormality evaluation must represent significant additional work beyond what's expected in a routine wellness visit 1

Billing Example Scenario

If you perform a Medicare Annual Wellness Visit and discover hypertension requiring evaluation of cardiovascular risk, medication initiation, and care coordination:

• Bill G0439 for the wellness visit 1
• Bill 99214 with modifier 25 if the hypertension evaluation required 30-39 minutes or met moderate complexity MDM criteria 1, 2
• Bill any laboratory tests (lipid panel, metabolic panel) separately with appropriate CPT codes 3