Confusion about the Medicare annual wellness visit

Since its debut last year, the Medicare annual wellness visit (AWV) has been an apparent source of ongoing confusion. That point was driven home to me again this week after I reviewed some Medicare claims data for this service.

As a reminder, there are two codes related to the AWV:  G0438 (includes a personalized prevention plan of service, initial visit) and G0439 ( includes a personalized prevention plan of service, subsequent visit). As the descriptors imply, the initial AWV, should precede a subsequent AWV, and at least 11 months should have elapsed since the month of the initial AWV before a subsequent AWV can be performed and billed.

Both services became Medicare benefits effective Jan. 1, 2011. In 2011, Medicare paid for G0439 (subsequent AWV) more than 50,000 times. Given the timing of the two services and given that a Medicare beneficiary could not receive G0438 (initial AWV) before Jan. 1, 2011, it is not clear how or why any claims for a subsequent AWV (G0439) would have been processed in 2011.

I suspect that G0439 was being reported in 2011 because of confusion regarding its relationship to the Initial Preventive Physical Exam (IPPE, also known as the "Welcome to Medicare Visit"), code G0402. As noted in "When A Medicare Annual Wellness Visit Follows a Welcome to Medicare Physical," FPM, May/June 2012, "The initial annual wellness visit must take place before a subsequent annual wellness visit in order to establish the required components that will be updated at subsequent visits. The initial annual wellness visit must occur no earlier than the same month of the year following the IPPE." In other words, the inital AWV follows an IPPE and a subsequent AWV follows an initial AWV.

Why the Medicare contractors reimbursed for G0439 in 2011 is a mystery. Apparently, they do not have the capacity or edits in place to recognize when a subsequent AWV is billed erroneously instead of an initial AWV.

For physician practices, this is more than just a matter of miscoding. It is also a matter of lost revenue. Medicare's average allowance for G0438 is $166; for G0439, it is approximately $111. That means that every time you bill G0439 when you should have billed G0438, you are leaving about $55 on the table. Maybe that's why the Medicare carriers were happy to process G0439 claims in 2011.

For more information on the AWV, check out the FPM Topic Collection on Medicare Annual Wellness Visits.