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Incident to Wellness Exams

Loni Posted Tue 03rd of October, 2017 16:01:25 PM
Since AWVs are not subject to incident-to rules (per Part B Insider March 30,2012 issue: Preventive Services: "Don’t Bill Annual Wellness Visit As ‘Incident To,’ CMS Says"), what is correct for preventive exams such as 99391-99397 with carriers that follow Medicare's incident-to policies and recognize NPPs? Does incident-to apply?
SuperCoder Answered Wed 04th of October, 2017 01:54:04 AM

Hi,

Kindly refer to the page 1 of the following article according to Medicare.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf

Hope this helps. Further query is welcome.

 

Loni Posted Wed 04th of October, 2017 11:41:46 AM
Thank you for your prompt response. What I'm looking for is guidance on NON-Medicare carriers (Blue Cross, Aetna, Tricare for example) that recognize NPPs and follow incident-to guidelines like Medicare does, but process "wellness" codes (such as 99395) rather than MC's G0439. This is based on this excerpt from the aforementioned article in my earlier inquiry: Avoid Incident-to for WTM, AWV Patients: Question 1: Can the "Welcome to Medicare" (WTM) exam or the annual wellness visit (AWV) be reported based on "incident-to" guidelines? Answer: No. The WTM exam, also referred to as the Initial Preventive Physical Examination (IPPE), "is not subject to incident-to billing," said Stephanie Frilling, health insurance specialist with CMS, during the call. "The payment policy for furnishing services incident-to a physician do not apply to the IPPE, as this service has its own benefit category," she said. "Likewise, the AWV is not subject to incident to rules," Frilling said. If a non-physician provider such as a nurse practitioner performs either of these services, he must bill under his own NPI, the CMS reps added.
SuperCoder Answered Thu 05th of October, 2017 08:39:47 AM

Hi,

For Medicare or Non-Medicare patients, service AWV and IPPE do not fall under the incident to benefit category. The NPP will bill under his own NPI.

Some insurance pay for NPP with modifier SA. Kindly check with your insurance.

 

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