Can You Bill an Office Visit With an Annual Wellness Visit?
Understand the specific requirements for billing Annual Wellness Visits and office visits together. Ensure accurate medical coding.
Medical billing for healthcare services involves understanding various service types and their appropriate application. This includes distinguishing between preventive care, such as an Annual Wellness Visit (AWV), and services focused on managing specific health concerns, often referred to as office visits or Evaluation and Management (E/M) services. A common question arises regarding whether these two distinct services can be billed together on the same day.
Understanding Annual Wellness Visits
An Annual Wellness Visit (AWV) is a preventive health service designed by Medicare to help beneficiaries stay healthy and plan for future health needs. It focuses on creating a personalized prevention plan to identify and address health risks, rather than diagnosing or treating existing medical conditions.
Components include a health risk assessment, which gathers information about a patient’s health status and risk factors. This assessment helps develop a personalized prevention plan, including a screening schedule. The visit also involves a review of medical and family history, current providers and medications, and screening for cognitive impairment. An AWV does not include a physical examination or the diagnosis and treatment of new or existing medical problems.
Understanding Office Visits
An office visit, or Evaluation and Management (E/M) service, involves the diagnosis and management of specific health conditions, symptoms, or illnesses. Unlike preventive services, E/M services are problem-oriented, focusing on active medical issues that require assessment and intervention. These visits address patient complaints or concerns, aiming to diagnose or manage a diagnosed condition.
Components of an E/M service include detailed history taking, exploring the patient’s chief complaint and related systems. A physical examination may be performed, focusing on affected body systems or a comprehensive review, depending on problem complexity. Medical decision-making involves the complexity of the problem, data reviewed, and risks of complications. Counseling and coordination of care are also common components, differentiating E/M services from an AWV.
Criteria for Billing Both Services Concurrently
Billing an Annual Wellness Visit (AWV) and an Evaluation and Management (E/M) service on the same date requires specific conditions. The E/M service must be a “significant, separately identifiable service” that extends beyond the routine scope of the AWV. This means the E/M portion must address a new health problem or an exacerbation of an existing one that necessitated additional physician work and medical decision-making.
For concurrent billing, the E/M service must demonstrate medical necessity, meaning it was required to diagnose or treat a specific illness or injury. For instance, if during an AWV, a patient mentions new symptoms like persistent chest pain, and the physician performs an evaluation, orders tests, and develops a treatment plan, that E/M service could be billed separately. It must represent additional, medically necessary work that would typically warrant an E/M code on its own.
Applying Correct Billing and Documentation Practices
When criteria for concurrent billing are met, correct billing and documentation practices are essential. To indicate a separate E/M service was performed on the same day as a preventive service, the Current Procedural Terminology (CPT) modifier -25 is appended to the E/M code. This modifier signifies a “significant, separately identifiable E/M service” was provided by the same physician or other qualified healthcare professional on the same day as another service. Its use informs payers the E/M service was distinct and medically necessary beyond the primary service.
Accurate and thorough documentation supports the use of modifier -25 and justifies both services. The medical record must clearly differentiate the AWV components from the E/M service components. Documentation for the E/M service must stand alone, detailing the patient’s complaint, relevant history, physical examination findings, medical decision-making, and the plan for the specific problem addressed. This separate documentation demonstrates the medical necessity and complexity of the E/M service, ensuring it is not merely an incidental part of the preventive visit.