Possibly because Medicare patients have been complaining about bills for physical exams they thought were covered, CMS says in a new Medicare transmittal (12,546) that physicians shouldn’t bill for annual wellness visits (AWVs) with certain codes—and urges them to obtain an advance beneficiary notice (ABN).^[1] If it all seems a bit counterintuitive, the transmittal reflects longstanding confusion about the fact that Medicare covers annual AWVs but not routine physical exams, which may be hard for patients and physicians to parse, an expert said. The development also may reflect ongoing compliance challenges with AWVs, which were the subject of a recent false claims settlement.

The Medicare transmittal reminds physicians that the Initial Preventive Physical Examination (IPPE) is billed with HCPCS code G0402, the first AWV is billed with G0438 and subsequent AWVs are billed with G0439. “These codes must be used for these services for Medicare beneficiaries,” CMS said. But the same isn’t true for CPT codes 99381-99397. As CMS says starkly, “Do not bill for AWV services using CPT codes 99381-99397.” They’re codes for comprehensive, preventive medicine evaluation and management services—essentially physical exams—which Medicare doesn’t cover because they’re considered routine.

The transmittal also urges physicians to get patients to sign an ABN agreeing to accept financial responsibility for the noncovered codes, even though that’s not the norm for routine care, as the transmittal explains. “A physician is not required to give a Medicare beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit not covered by Medicare such as comprehensive preventive Medicine evaluation and management services in the CPT code range 99381-99397. However, in accordance with Pub. 100-04, Chapter 50, section 50.2.1, physicians are strongly encouraged to provide an ABN to beneficiaries when providing and billing for a preventive medicine service (CPT codes 99381- 99397). The physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat an illness or injury.”