Watch Out for Medicare Wellness Visit Glitches

Seniors and doctors alike are hot for the highly publicized new wellness visit under Medicare, but a story about claim denials from contractors is apparently causing a bit of alarm.

Last week, news broke that a quarter of one Texas doctor’s annual wellness visits billed between Jan. 3 and Jan. 19 were denied by his Medicare carriers as an uncovered benefit. 

Apparently there was some confusion about the implementation date; some contractors thought it was April 4, although the benefit went into effect Jan. 1. Their translation: Don’t pay claims until April. Though the issue was resolved in Texas (several of the Medicare contractors announced that the error had been corrected and physician claims will be reprocessed), it’s good to keep tabs on what’s happening - and what the wellness visit is all about.

According to the Patient Protection and Affordable Care Act, the new “wellness visit” in effect as of Jan. 1 calls for doctors to take a comprehensive health-risk assessment that establishes the individual’s medical history and vitals, create a list of current providers and suppliers involved in medical care, and make recommendations for a screening schedule for the next five to ten years. (Click here for a full list of visit requirements).

The visit may be conducted by physicians, physician assistants, nurse practitioners, clinical nurse specialists, and other select healthcare professionals.

Contrary to patient and physician expectations, the wellness visit it is not a physical exam or preventive medicine service, as defined by CPT codes 99381-99397, notes coding expert Betsy Nicoletti: Those services will still not be covered and if billed they will be denied as routine by Medicare.