A Guide to Implementing and Coding Medicare's Annual Wellness Visit

The Initial Preventive Physical Examination (IPPE)/Welcome to Medicare Preventive Visit is a once per lifetime benefit that may be provided only within the first 12 months of enrollment in Medicare Part B. The AWV is covered only after the first 12 months of Medicare Part B coverage have passed. The AWV can be provided annually once per 12-month period thereafter.

No. Patients are only eligible within the first 12 months of Medicare Part B enrollment for an IPPE/Welcome to Medicare Preventive Visit.

No. The AWV does not replace a complete head-to-toe physical exam. A yearly physical CPT codes: 99381-99397 is never a covered service.

Better patient care starts with preventive wellness visits. Download the AAFP’s patient flier and use it to talk with your Medicare patients about the importance of scheduling a free, personalized prevention visit with you.

• Download the patient flyer »(1 page PDF)
• Download the patient letter »(1 page PDF)

The AWV is covered 100% by Medicare. There is no deductible or coinsurance owed by the patient.

Medicare pays 100% for the AWV and focuses on health promotion and prevention. A problem-oriented visit is not part of this benefit and is subject to deductibles or coinsurance.

Yes. The patient may be asked to complete portions(www.cms.gov) of the IPPE or AWV prior to the appointment, such as demographic information and self-assessment of health status. The AAFP’s FPM Journal has several patient surveys and questionnaires for patients and/or your staff to complete.

1. Administer a health risk assessment (HRA). Access a health risk assessment and other patient surveys and questionnaires at the AAFP’s FPM Journal. Keep in mind the following items when administering an HRA:

• The practice or beneficiary may complete an HRA before or during the AWV.
• Communication needs (such as individuals with limited health literacy or English proficiency) may need to be accounted for to fit the patient’s needs.
• An HRA should not take more than 20 minutes to complete.
• At a minimum, collect and document information about:
  • Demographics;
    
  • Self-assessment of health;
    
  • Psychosocial risks;
    
  • Behavioral risks;
    
  • Activities of daily living (ADLs), including, but not limited to dressing, bathing, and walking; and
    
  • Instrumental ADLs, including, but not limited to shopping, housekeeping, medication management, and the handling of finances.

2. List current providers and suppliers of health care.

3. Establish medical and family health history.

• At a minimum, collect and document information about:
  • Medical events of parents, siblings, and children, including disease(s) that are hereditary or place the beneficiary at increased risk.
    
  • Past medical and surgical history, including illnesses, hospitalization(s), operations, allergies, injuries, and treatments.
    
  • Current medications and supplements.

4. Document risk factors for potential depression, including current or past experiences with depression or other mood disorders.

• For beneficiaries without a current diagnosis of depression, use the appropriate screening instruments, including this patient health questionnaire(www.uspreventiveservicestaskforce.org) from the U.S. Preventive Services Task Force (USPSTF). You may select from various standardized screening tests designed for this purpose that are recognized by national professional medical organizations.

5. Review functional ability and level of safety.

• Use direct observation, select appropriate screening questions, or utilize a screening questionnaire from recognized national professional medical organization. At a minimum, these should assess:
  • Ability to perform ADLs;
    
  • Fall risk(www.cdc.gov);
    
  • Hearing impairment; and
    
  • Home safety.

6. Conduct a general health assessment.

• Obtain and document information about:
  • Height;
    
  • Weight;
    
  • Body mass index (BMI);
    
  • Blood pressure; and
    
  • Other routine measurements appropriate to gather a thorough medical or family history.
• Detect cognitive impairment(s) the beneficiary may have by the:
  • Direct observation of the beneficiary’s cognitive function, taking into account information obtained from the beneficiary directly or from concerns by family members, friends, or caretakers.

7. Counsel the beneficiary.

• Establish a written screening schedule, such as a checklist for the next 5-10 years. Base the written screening schedule on:
  • Age-appropriate preventive services covered by Medicare;
  • Recommendations from the USPSTF and the Advisory Committee on Immunization Practices (ACIP); and
  • The beneficiary’s HRA, health status, and screening history.
• Establish a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or underway for the beneficiary. These may include:
  • Any mental health conditions or any risk factors or conditions identified through the IPPE; and
  • A list of treatment options and their associated risks and benefits.
• Furnish personalized health advice to the beneficiary and provide a referral to health education, preventive counseling services, or programs, as appropriate. Referrals to programs are aimed at:
  • Fall prevention;
    
  • Nutrition;
    
  • Physical activity;
    
  • Tobacco use and cessation; and
    
  • Weight loss.

8. Furnish at the beneficiary's discretion, advance care planning services.

The following health care professionals can perform the AWV: a physician who is a doctor of medicine or osteopathy, physician assistant (PA), nurse practitioner, certified clinical nurse specialist, or medical professional, including a health educator, registered dietitian, nutrition professional or other licensed practitioner, or a team of medical professional working under the direct supervision of a physician (doctor of medicine or osteopathy).

• IPPE – G0402
  
• EKG/ECG with IPPE – G0403
  • Other codes that are applicable – G0404 and G0405
• Initial AWV – G0438 (includes personalized prevention plan of service)
  
• Subsequent AWV – G0439 (includes personalized prevention plan of service)

The yearly physical exam is not a covered benefit for the beneficiary and would need to be billed to the patient. However, Medicare pays 100% for the AWV. After the first 12 months of Medicare Part B enrollment, the beneficiary is eligible for the initial AWV and subsequent AWVs. This allows AWVs to become an ongoing source of revenue.

Yes. The appropriate E/M service may be billed in addition to the AWV. Report the CPT code with modifier -25. The E/M service is subject to a co-payment.

No consent form is required for this benefit.

This would depend on which provider submitted the claim first. The AWV can only be billed once in a 12-month period for a single beneficiary.

Contact your local Medicare administrative contractor (MAC) to verify whether the coverage requirements concerning time intervals between services have been met.

If the patient has moved or spent part of the year in another part of the country (e.g., is a “snowbird”), you may also need to contact the MAC for the part of the country where the patient lived previously. You can identify the relevant MAC and their contact information through this interactive map(www.cms.gov) from CMS.

Alternatively, you may want to access the CMS HIPAA Eligibility Transaction System (HETS) Help (270/271)(www.cms.gov), a secure website you can use as your primary Medicare information source for patient eligibility and liability. HETS is available at no cost to you at any time, with limited functionality outside of normal business hours.

After viewing this webcast, you should be able to:

• Review CMS Annual Wellness Visit (AWV) requirements and summarize visit elements.
• Identify how AWV findings can close care gaps and engage patients.
• Examine financial and quality implications of incorporating the Medicare Annual Wellness Visit as a means of practice improvement.
• Recognize the importance of AWV in relation to value-based payment.
• Link AWV with other care management services such as Transitional Care Management, Chronic Care Management Services, and Advance Care Planning.

Estimated time required to complete the full webcast: 60 minutes

Original release date of webcast: April 4, 2017

Download the slide presentation and addendum resources for the AWV: Getting Paid for What We Do Best webcast »(36 page PDF)

Disclaimer

The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.