CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preventive Services for Medicare Advantage Plans

Governs coverage, coding, and cost-sharing rules for preventive services for Blue Cross Blue Shield - Rhode Island Medicare Advantage members and provides provider billing guidance to ensure correct claims processing.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Services for Medicare Advantage Plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2011

Next Review DateN/A

Key ActionNo prior authorization is required for preventive services under this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

nonePrior authorization requirement

no cost sharePreventive services covered without member cost share

some cost-shareCertain services retain deductible/coinsurance

variesFacility cost-sharing when mixed services

Coverage and Billing Rules for Preventive Services

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General coverage rules

High-level coverage and billing guidance for preventive services:

Preventive services defined in the coding section are covered at no cost share for members, except where CMS specifies cost sharing applies.

Claims must be filed according to the coding and diagnosis guidelines to ensure correct claims processing under the appropriate member benefit.

If an Annual Wellness Visit (G0438 or G0439) and an Annual Physical Exam (99385-99387 or 99395-99397) are performed on the same date of service, documentation must support use of both codes; the Annual Physical Exam is not considered a preventive service for cost-share waiver purposes — refer to the member Evidence of Coverage for applicable benefits.

Depression screening (G0444) will not be reimbursed when filed with the initial Annual Wellness Visit (G0438) because G0438 includes a depression screening; G0444 may be reimbursed when documented with a subsequent AWV (G0439).

Facility cost sharing: when preventive and non-preventive services are performed concurrently, facility cost sharing applies only when the higher-priced procedure is non-preventive; if the higher-priced procedure is preventive, facility cost sharing may not apply.

Benefits and cost-sharing may vary by group/contract; always refer to the member Evidence of Coverage for specific preventive benefit and cost-sharing determinations.

Codes, Same-day Rules, and Billing Notes

Example preventive and related codesCPT | HCPCS | mixedCovered

G0438	Annual Wellness Visit, initial
G0439	Annual Wellness Visit, subsequent
G0444	Depression screening
99385-99387	Initial comprehensive preventive medicine evaluation (annual physical) — example codes cited
99395-99397	Periodic comprehensive preventive medicine evaluation (annual physical) — example codes cited

Same-day AWV and Annual Physical — documentation requirements (inv-03)

Requirement when AWV and Annual Physical are same dayDocumentation must support billing both the AWV (G0438/G0439) and the Annual Physical (99385-99387 or 99395-99397); documentation must meet requirements for use of both codes.

Annual Physical classificationThe Annual Physical Exam (99385-99387 or 99395-99397) is not considered a preventive service for cost-share waiver purposes; check the member's Evidence of Coverage for applicable benefits.

Provider types notedSame-day billing guidance applies when performed by a Primary Care Provider (PCP), Physician Assistant (PA), or Nurse Practitioner (NP).

Depression screening overlapG0438 (initial AWV) includes depression screening; do not bill G0444 with G0438.

Subsequent AWV and depression screeningG0439 (subsequent AWV) does not inherently include the depression screening requirement; G0444 may be reimbursed when documented with G0439.

Key Definitions and Service Designations

Preventive services — coverage and billing (inv-05)

Definition of preventive servicesServices defined in the coding section of this policy are covered at no cost share for the member, subject to CMS-specified exceptions.

Basis for no cost shareMany covered preventive services are those with USPSTF A or B recommendations or statutorily defined clinical laboratory preventive services (Affordable Care Act provisions).

Claims filing guidanceTo ensure correct claims processing, claims must be filed according to the coding and diagnosis guidelines in this policy (diagnosis in primary position as noted on the coding grid).

Variation by contractBenefits may vary by group/contract—refer to the member Evidence of Coverage for specific preventive benefits and any applicable cost sharing.

Annual Physical Exam — definition and cost-share (inv-06)

Codes for Annual Physical ExamCPT codes 99385-99387 (initial comprehensive preventive medicine evaluation) and 99395-99397 (periodic comprehensive preventive medicine evaluation).

Cost-share statusThe Annual Physical Exam is not considered a preventive service for the cost-share waiver; subject to member's Evidence of Coverage for benefit and cost sharing.

Documentation requirement when co‑occurring with AWVIf performed same day as an AWV, documentation must reflect requirements for both codes are met to bill both services.

Annual Wellness Visit (AWV) — codes and screening rules (inv-07)

AWV codesHCPCS codes G0438 (initial Annual Wellness Visit) and G0439 (subsequent Annual Wellness Visit).

Components included in G0438G0438 includes a depression screening by a standardized instrument, an assessment of functional ability, and evaluation of level of safety.

Depression screening billing ruleDepression screening (G0444) will not be reimbursed when filed with the initial AWV (G0438) because G0438 includes depression screening.

G0439 limitationsThe subsequent AWV (G0439) does not inherently include the requirements for depression screening; G0444 may be reimbursed when documented with G0439.