CONTENT AND DOCUMENTATION REQUIREMENTS

System/Body Area : Constitutional 

Elements of Examination : Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) 

System/Body Area : Eyes

Elements of Examination : 

• Inspection of conjunctivae and lids 
• Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry) 
• Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages) 

System/Body Area : Ears, Nose, Mouth and Throat

Elements of Examination : 

• External inspection of ears and nose (eg, overall appearance, scars, lesions, masses) 
• Otoscopic examination of external auditory canals and tympanic membranes 
• Assessment of hearing (eg, whispered voice, finger rub, tuning fork) 
• Inspection of nasal mucosa, septum and turbinates 
• Inspection of lips, teeth and gums 
• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

System/Body Area : Neck

Elements of Examination : 

Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass) 

System/Body Area : Respiratory

Elements of Examination : 

• Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) 
• Percussion of chest (eg, dullness, flatness, hyperresonance)
• Palpation of chest (eg, tactile fremitus) 
• Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Wellness Visit Submission Codes CPT g0402, g0438, G0439

Please submit the following code for the one-time Welcome to Medicare Visit:
• G0402

Please submit one of the following codes for the Annual Wellness Visit:
• G0438 (first visit)
• G0439 (subsequent visit)

In 2015, our plans also cover an Annual Routine Physical Examination by the member’s Primary Care Physician (PCP) and can be billed using the following codes:
• 99385-99387
• 99395-99397

Annual Routine Physical Examination coverage:

• If you bill these 99XXX codes, you must provide a head-to-toe exam and cannot bill for a separate breast and pelvic exam, a Digital Rectal Exam (DRE), or counseling to promote healthy behavior. See the Definitions section for details on the specific components included in the visit. All UnitedHealthcare Medicare Advantage plans for individuals include this benefit in 2015. Coverage on employer group Medicare Advantage plans may vary

All plans offer a Pap/Pelvic Exam (including pelvic exam and the pap collection with coverage periodicity following Medicare guidelines: covered annually for those at high risk and every two years for women not considered high risk) for a $0 copay. A separate Evaluation and Management (E/M) code may be billed only if a separately identifiable E/M service was provided. The following code is accepted:

• Exam: G0101

When members see an obstetrician or gynecologist who is not their assigned PCP for a routine pap/pelvic exam, only the Medicare-covered annual pap/pelvic service should be performed and billed. Members should be referred to their assigned PCP if a more comprehensive preventive service is warranted.