u/GeneralistRoutine189

TL;DR how do you find out if a Medicare Advantage can get a 99397? “many but not all plans cover” Goal: MA 99214 AWV 99397 visits. Do you ever split to 99214 AWV one day and 99214 99397 another and does that help compared to both same day?

I have asked my front desk to call case by case and it can be 10-15 minute per patient. There does not seem to be a way is use a portal like for referral management to check this.

Weeds:
System policy is “you bill it patient pays it, no write offs” So: bill everyone with MA: 2wrvu and system earns 200+. But some percent of the people get a bill for 200+ bucks.

They bill 99214-25 G0439 99307-GY with GY being required per them and “patient must pay if non-covered” At least one plan said online to bill 99214 G0439-25 99397-25 which sounded both crazy and specifically different from all the other rules, so designed to get denials.

revenue cycle/billing people say it is hard to track denials, or successful claims by plan. Which seems it should be easy to me. They also say that one MA plan (at random, Aetna) may have some plan agreements that cover for one group (California MA plan) and not another (Ohio MA plan)- and that the MA plans refuse to tell them about this specific coverage.

99214 G2211 veinipuncture: OK? Or G2211 does not apply and is removed?
Would love anyone’s perspective.

My site has been wrong before but firmly claims that drawing blood at Dr’s in-office labs OR at a remote lab site with same Tax ID = G2211 does not apply.

In early 2026, G0136 changed from SDOH to what looks like "diet or exercise" assessment -  “administration of a standardized, evidence-based assessment of physical activity and nutrition, 5–15 minutes, not more often than every six months.” Are you all coding this? Our HRA includes the Physical Activity Vital Sign - if I add a nutrition screener and get to 5 minutes total diet/exercise, could I code G0136? I'm also interested diet OR exercise vs diet AND exercise -- specifically how you address this.

I am feeling like a patient seen for GLP1 could get a G0136 (diet/ex) or brief obesity counseling or G0537 ascvd etc - or a combination. Frustratingly my site doesn't have any standardized phrases, nor any coding assistance to avoid billing too freuqently.

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The tool used must be tested and validated through research. Examples of nutrition assessments include the Mini-EAT tool, Starting the Conversation: Diet tool, and Short Dietary Assessment Instruments. --> what is the most useful & concise?

Examples of physical activity assessments include the Physical Activity Vital Sign tool {EPIC's] , CHAMPS Physical Activity Questionnaire for Older Adults, Rapid Assessment of Physical Activity (RAPA), or Telephone Assessment of Physical Activity (TAPA). The code is payable when either or both assessments are performed.

Our coding/compliance group is quite conservative. They state 5 minutes is required to bill. What say you (coders) or your organization? I think the descriptor may say 5-15, but I've seen some that are 50% of a time frame, and some like G0444 Medidicare Depression screening where 5-15 may be in the descriptor but is explicitly not required by CMS.

Their suggested language: Patient with at least one ASCVD risk factor, with no CVD, scored *** on ASCVD risk assessment. Time spent ***. (Associate code w/ the ASCVD risk factor. Of course they want the provider to do this manually)

TL;DR do you get paid for G2211 when you do an office visit plus POCT. I don’t since my site adds -25 to the POCT which removes the G2211.

On another forum I read that some are getting paid by Medicare when there are POCT.

At my site, we are told that veinipuncture or point of care tests mean a -25 is added to the claim. The CMS guidance says that 992xx/home visits + any CMS covered prevention can have a G2211 even if there is a -25. But -25 for non-prevention separate services = G2211 will be removed.

So if I do htn dm poc a1c then g2211 does not apply (poct has a -25 and is not for prevention). But if I do htn dm and the lab was 2 days ago, g2211 is fine.

Options:
A) coding/compliance/rev cycle is wrong
B) they are adding a -25 to poct when CMS doesn’t require it, and that is why G2211 is being removed (eg they are wrong for that specific reason)
C) they are correct

Our large group does a single $/wRVU but excluded wRVU for CCM when they increased $/wRVU (increasing the $/wRVU for office visits made up for removing ccm credit). We are going to do PIN and APCM

are you getting paid for these? If so, how? (WRVU, flat$ amount, only if it is more complex?)

background:
ccm: Chronic care management-2+ applicable chronic illnesses)
PIN (principal illness navigation- 1 chronic illness) APCM (advanced primary care management)- different levels depending on patient complexity.
CCM>PIN>APCM.

All of these programs come with either wRVU or $$. Ancillary staff largely does this but I get a fair amount of notes to read/digest/sign and change care plans without visits at times, as is the intent of the ccm program.

Of course management feels that “staff basically does the work” which is why they feel it’s appropriate not to compensate for this.