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Medicare’s Annual Wellness Visit (AWV) is a way for your practice to keep patients as healthy as possible. As health care moves from volume- to value-based models, the AWV addresses gaps in care and enhances the quality of care you deliver. A personalized prevention plan created for the Medicare beneficiary is a way to improve patient engagement and promote preventive health care.
The Annual Wellness Visit (AWV) allows practices to gain information about the patient, including medical and family history, health risks, and specific vitals. Not to be confused with a complete physical examination, the purpose of the AWV is to review the patient’s wellness and develop a personalized prevention plan. The services provided during the AWV are different from a typical preventive care visit and expand to include emotional and psychological well-being, in addition to the patient’s physical well-being. The AWV provides an opportunity for physicians to improve the quality of care, assist in patient engagement, and optimize payment opportunities.
The CPT codes for Annual Wellness Visits are G0438 for the initial visit and G0439 for subsequent visits. These codes are used to bill Medicare for comprehensive wellness assessments and personalized prevention plans.
It is important to remember that code G0438 is for the first AWV only. The submission of G0438 for a beneficiary for which a claim code of G0438 has already been paid will result in a denial. This benefit is covered at 100% for the beneficiary.
Health Care Professionals Who May Furnish and Bill AWV:
Non-physicians must legally be authorized and qualified to provide AWVs in the state in which the services are furnished.
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.
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:
2. List current providers and suppliers of health care.
3. Establish medical and family health history.
4. Document risk factors for potential depression, including current or past experiences with depression or other mood disorders.
5. Review functional ability and level of safety.
6. Conduct a general health assessment.
7. Counsel the beneficiary.
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).
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:
Estimated time required to complete the full webcast: 60 minutes
Original release date of webcast: April 4, 2017
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.