Billing & Coding for Wellness Services

Question: Dr Kotlar, “Do insurance companies pay for wellness services?”

Answer: Yes, some carriers pay for wellness exams, preventive medicine services and maintenance care. Here are a few examples:

1. Preventive Medicine Exam – New Patient:
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient;

99381: infant (age younger than 1 year)
99382: early childhood age (age 1 through 4 years)
99383: late childhood age (age 5 through 11 years)
99384: adolescent age (age 12 through 17 years)
99385: 18-39 years
99386: 40-64 years
99387: 65 years and over

2. Preventive Medicine Exam – Established Patient:
Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient;

99391: infant (age younger than 1 year)
99392: early childhood age (age 1 through 4 years)
99393: late childhood age (age 5 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/DO – these codes are not covered by Medicare.

3. Initial Preventive Physical Examinations (IPPE) – aka the Welcome to Medicare Visit:
This is a “once-in-a-lifetime” covered Medicare benefit.  It does not include lab tests.  Co-pay, co-insurance and deductible are waived. Use HCPCS code G0402 for the initial preventive physical examination. This is a face-to-face visit and the services are limited to new beneficiaries during the first 12 months of Medicare enrollment.

4. Medicare Annual Wellness Visits (AWV):
The AWV includes the establishment of, or update to, the patient’s medical history, family history, height, weight with BMI and blood pressure. The goals are health promotion and disease prevention. Clinical lab tests are not included, however they can be ordered when appropriate. An AWV is not an annual routine physical. Medicare does not pay for routine physicals.

Use HCPCS code G0438 for the initial AWV. This includes a personalized prevention plan of service. This service is covered one time in the 2nd year of eligibility. Co-pay, co-insurance and deductible waived.

Use HCPCS code G0439 for the subsequent AWV. This includes a personalized prevention plan of service. This service is covered one year after the initial AWV. It does not include lab tests.  Co-pay, co-insurance and deductible waived.

5. Physical or Manipulative Therapy Performed for Maintenance rather than Restoration:
Use HCPCS code S8990, except when billing Medicare. Code S8990 can be used for chiropractic adjustments once the patient has reached maximum therapeutic benefit and has transitioned to preventive/wellness care or performance enhancing care.

According to Aetna, preventive or maintenance chiropractic manipulation has been defined as elective health care that is used to prevent disease, promote health and enhance the quality of life.  This care may be provided after maximum therapeutic improvement, without a trial of withdrawal of treatment, to prevent symptomatic deterioration or it may be initiated with patients without symptoms in order to promote health and to prevent future problems. Preventive services may include patient education, home exercises, and ergonomic postural modification.

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. Medicare considers chiropractic spinal maintenance therapy a non-payable service, therefore supply the patient with an ABN and follow all ABN rules. If the patient chooses option 1 on the ABN, submit the claim with spinal CMT codes (e.g., 98940, 98941, 98942) and the GA modifier – do not use S8990. Just a reminder, the only Medicare covered service when performed by a chiropractor is spinal manipulation.

Diagnosis codes associated with chiropractic wellness encounters include:
• Z00.00 – Encounter for general adult medical examination without abnormal findings
• Z00.129 – Encounter for routine child health examination without abnormal findings
• Z01.30 – Encounter for examination of blood pressure without abnormal findings
• Z02.1 – Encounter for pre-employment examination
• Z02.5 – Encounter for examination for participation in sport
• Z02.6 – Encounter for examination for insurance purposes
• Z02.71 – Encounter for disability determination
• Z13.21 – Encounter for screening for nutritional disorder
• Z13.82 – Encounter for screening for musculoskeletal disorder
• Z13.820 – Encounter for screening for osteoporosis
• Z13.828 – Encounter for screening for other musculoskeletal disorder
• Z13.85 – Encounter for screening for nervous system disorders
• Z13.850 – Encounter for screening for traumatic brain injury
• Z13.858 – Encounter for screening for other nervous system disorders

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Marty Kotlar, DC, CPCO, CBCS is the President of Target Coding. Dr. Kotlar is Certified in CPT Coding, Certified in Healthcare Compliance and has been helping chiropractors nationwide with billing, compliance, coding and documentation for over 10 years. Target Coding can be reached at 1-800-270-7044, website – www.TargetCoding.com, email – info@targetcoding.com.