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

    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. 

    What is the Medicare Annual Wellness Visit (AWV)?

    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.

    How to use codes G0438 and G0439

    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.

    Selected requirements and components for G0438 (initial visit) 

    • Billable for the first AWV only.
      • Patient is eligible after the first 12 months of Medicare coverage.
      • For services within the first 12 months, conduct the Initial Preventive Physical Exam (IPPE), also referred to as the Welcome to Medicare Visit (G0402).
    • The patient must not have received an IPPE within the past 12 months.
    • Administer a Health Risk Assessment (HRA) that includes, at a minimum: demographic data, self-assessment of health status, psychosocial and behavioral risks, and activities of daily living (ADLs), instrumental ADLs including but not limited to shopping, housekeeping, managing own medications, and handling finances.
    • Establish the patient’s medical and family history.
    • Establish a list of current physicians and providers that are regularly involved in the medical care of the patient.
    • Obtain blood pressure, height, weight, body mass index or waist circumference, and other measurements, as deemed appropriate.
    • Assess patient’s cognitive function.
    • Review risk factors for depression, including current or past experiences with depression or mood disorders.
    • Review patient’s functional ability and safety based on direct observation, or the use of appropriate screening questions.
    • Establish a written screening schedule for the individual, such as a checklist for the next 5 to 10 years based on appropriate recommendations.
    • Establish a list of risk factors and conditions for primary, secondary, or tertiary intervention.
    • Provide personalized health advice to the patient, as appropriate, including referrals to health education or preventive counseling services and programs.
    • At the patient's discretion, furnish advance care planning services.

    Selected requirements and provisions for G0439 (subsequent visit)

    • Billable for subsequent AWV.
    • The patient cannot have had a prior AWV in the past 12 months.
    • Update the HRA.
    • Update the patient’s medical and family history.
    • Update the current physicians and providers that are regularly involved in providing the medical care to the patient, as developed during the initial AWV.
    • Obtain blood pressure, weight (or waist circumference, if appropriate), and other measurements, as deemed appropriate.
    • Assess patient’s cognitive function.
    • Update the written screening schedule checklist established in the initial AWV.
    • Update the list of risk factors and conditions for which primary, secondary, and tertiary interventions are recommended or underway.
    • Provide personalized health advice to the patient, as appropriate, including referrals to health education or preventive counseling services and programs.
    • At the patient's discretion, the subsequent AWV may also include advance care planning services.

    Health Care Professionals Who May Furnish and Bill AWV:

    • Physician
    • Physician assistant (PA)
    • Nurse practitioner (NP)
    • Clinical nurse specialist (CNS)
    • Medical professional (including a health educator, registered dietician or nutrition professional, or other licensed practitioner) or a team of medical professionals working under the direct supervision of a physician.)

    Non-physicians must legally be authorized and qualified to provide AWVs in the state in which the services are furnished.

    5 Tips for getting started with AWVs

    • AWVs can be provided to all Medicare Part B patients.
    • Use this service to identify patients who would benefit from a discussion regarding their self-management goals.
    • Choose patients the staff has identified as highest risk (i.e., staff are concerned that the patient is unstable or may be more likely to need additional services or have recently been to the ER).
    • Use this service to risk stratify your patient population.
    • Use this service to document diagnoses and conditions to accurately reflect patient severity of illness (hierarchical condition category [HCC] coding) and risk of high-cost care. 

    Answers to Common Questions about the AWV

    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:

    • 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:

    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.

    AWV Tutorial: Getting Paid for What We do Best

    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.

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