Update February 28, 2018
The first chart I posted with this article had an error. Thanks to the sharp eyed member who found my error and pointed it out. We’ve posted the corrected chart.
Someone asked where to find the CMS chart with the intraservice guidelines. It is hidden deep on the CMS site! It is in the files that go with the 2018 Final Rule. Scroll down to about the 20th on the list and download 2018 List of Preventive Services Billed with Prolonged Preventive Codes.
New in 2018!
Two new codes to for use with Medicare covered preventive services.
Did you (or your clinician) ever have a wellness visit that took a really, truly, madly long time? And wondered what—if anything—you could bill with it? Wonder no more.
CMS has developed codes to be used with preventive medicine services that are time based. These codes can be used in addition to the Welcome to Medicare visit, and initial and subsequent wellness visits. These prolonged codes may also be used with other preventive services. Download a complete chart of codes. I’ll discuss the other services later in the article.
Prolonged services and wellness visits
There are two new HCPCS codes that can be billed for wellness visits that are especially time consuming.
The provider must meet the threshold time for the visit, and half of the prolonged services time.
At an Open Door Forum, I asked if CMS was following the CPT time rule for prolonged codes, and was told that they were. The full time of the wellness visit must be met, however, before adding the time for the prolonged code.
New HCPCS codes
G0513 Prolonged preventive service(s) (beyond the typical service of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (listed separately in addition to code for preventive service)
G0514 Prolonged preventive service(s) (beyond the typical service of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (listed separately in addition to code for preventive service)
CPT time rule
A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes). A second hour is attained when a total of 91 minutes have elapsed.
Clinical example for G0513
Remember, this is physician/NP/PA time, not staff time.
Much of the work of a wellness visit, data collection, recording the patient’s history, screening for depression and activities of daily living, is done by staff members. Their time is not counted for either the wellness visit code or the additional prolonged services code.
During an initial wellness visit, the physician reviews the health risk assessment, screenings and past medical, family and social history with the patient. In developing the personalized prevention plan, the physician spends a total of 50 minutes (meeting the 30 minute threshold for the wellness visit and the 20 minute threshold for the prolonged care) in discussing risk factor reduction, the importance of the flu vaccine and screening. The long discussion includes reviewing reasons for colorectal screening and encouraging the patient to have a colonoscopy. These wellness prolonged services codes are not subject to co-pay and deductible.
Wellness visit topics
- Safety at home
- Diet, exercise
- Fall prevention
- Smoking, alcohol and other substance use
- Lifestyle behaviors that increase risk
- Importance of immunizations and screening
When to add a problem-oriented E/M visit
Sometimes, the visit involves management of conditions or illnesses. The clinician reviews the status of chronic diseases or an acute condition. This additional time and work of a problem-oriented visit is documented in the HPI with a discussion of the condition or symptoms and in the assessment and plan, with comments on the status of the problems and management. This is more accurately coded with an E/M service and a wellness visit. The E/M service will be subject to a co-pay and deductible.
My advice: don’t add a problem oriented E/M code and a wellness visit
The final rule does not say this directly, but reading between the lines I believe that if there are three codes on the claim form (wellness visit, prolonged and problem oriented) G0513 and G0514 will be denied. This is something else to look for in January, when the MACs take the provisions of the Final Rule and implement the policies.
Here is what the Final Rule said.
“We proposed that HCPCS codes G0513 and G0514 could only be billed with Medicare- covered preventive services. Beneficiary coinsurance and deductible would not be applicable for HCPCS codes G0513 and G0514 because the codes can only be reported to describe prolonged portions of services where beneficiary coinsurance and deductible are not applicable.”
It isn’t definitive however, and this advice is my opinion.
I don’t know. If I find any information I’ll update this article. If you have information from your MAC about whether a modifier will be needed, please email me. Modifiers are not required on CPT add-on, but it isn’t clear to me if these are considered add-on codes.
Some of the other services on the list, such as counseling for lung cancer screening, are services provided by a physician, NP or PA.
These work in the same way as adding G0513 or G0514 to a wellness visit. The provider must meet the entire time for the preventives service (the chart is included again below) and then half of the threshold time for G0513, 16 minutes more.
For the diagnostic services, such as mammography, the prolonged codes may be used on the technical component of the service, if the technician meets the threshold time plus half of the prolonged care time.
|Code||Brief description||Intraservice time of physician, NP, PA||Threshold to bill G0513||Threshold to bill G0513 & G0514|
|G0402||Welcome to Medicare visit||30||46||76|
|G0438||Initial annual wellness visit||30||46||76|
|G0439||Subsequent annual wellness visit||25||41||71|
|Q0091||Obtaining a screening pap smear||16||32||62|
|G0101||Pelvic and clinical breast exam, screening||10||26||56|
|G0104||Flexible sigmoidscope, cancer screening||17||33||63|
|G0105||Screening colonoscopy, high risk individual||30||46||76|
|G0121||Screening colonoscopy, low risk individual||30||36||76|
|G0296||Visit to determine lung cancer screening eligibility||15||31||61|
|Code||Brief description||Typical time with staff||Threshold to bill G0513||Threshold to bill G0513 & G0514|
|76706||Ultrasound, abdominal aorta, real time screening for AAA||32||48||78|
|76977||Ultrasound bone density measurement and interpretation, peripheral site(s), any method||7||23||53|
|77067||Screening mammography, bilateral||22||38||68|
|77063||Screening digital breast tomosynthesis, bilateral||12||28||58|
|77078||CT, bone mineral density study, 1 or more sites, axial skeleton||29||45||75|
|77080||Dual-energy X-ray absorptiometry, bone density study, 1 or more sites axial skeleton (eg, hips, pelvis, spine)||33||49||79|
|77081||Dual-energy X-ray absorptiometry, bone density study, 1 or more sites appendicular skeleton (peripheral) (eg, radius, wrist, heel)||22||38||68|
Payment for G0513 and G0514
|Code||Brief description||wRVU||Total non-facility RVU||Total non-facility national fee||Total facility RVU||Total facility national fee|
|G0513||Prolong prev svcs, first 30m||1.17||1.84||66.22||1.73||62.26|
|G0514||Prolong prev svcs, addl 30m||1.17||1.84||66.22||1.73||62.26|
This is good news for primary care!