Medicare Annual Wellness Visit

AWV Uncorks New Revenue Stream, Improves Health Care Quality

February 24, 2017 12:52 pm Sheri Porter

Family physicians have a lot going on in their practices as they try to keep up with CMS regulations and necessary practice changes. Some physicians find that the flurry of activity around implementing value-based payment models -- unleashed by the Medicare Access and CHIP Reauthorization Act -- gets in the way of taking care of patients.

Gary Bevill, M.D., takes the time he needs to provide a Medicare annual wellness visit for one of his senior patients.

But in the case of the Medicare annual wellness visit (AWV), physicians get to do what they love -- improve the health and welfare of patients -- and at the same time, gain valuable experience in providing the patient-centered, team-based care that embodies the payment models of the future.

"The annual wellness visit is, I believe, the best opportunity to truly perform a preventive evaluation for our senior population -- a comprehensive assessment of their overall health," said Arnold Cuenca, D.O., a 10-year family medicine veteran currently practicing at OptumCare Medical Group in Ladera Ranch, Calif., and a member of the Family Practice Management (FPM) advisory board.

Cuenca, author of a 2012 article in FPM on taking a team-based approach to the AWV, told AAFP News, "We focus a lot on taking care of the sick patient who is acutely ill, chronically ill. But part of family medicine is preventive, and that really is what this visit is all about, and why I think it's important."

Providing the AWV also helps practices on another front by "achieving the quality metrics that are in the fee-for-value kind of environment that we are in today," Cuenca added.

Story Highlights
  • Physicians who learn to provide the Medicare annual wellness visit will find the service is good for Medicare patients, helps the practice improve on quality and opens a new revenue stream.
  • This preventive evaluation for seniors is covered 100 percent by Medicare and can be combined with another visit with the addition of a code modifier.
  • The visit can be repeated annually and generates additional money for the practice -- as much as $17,500 for a practice with 150 Medicare patients.

Another important benefit that physicians must consider is the generation of a new revenue stream. Remember, the visit is paid 100 percent by Medicare, and as a repeating code, the service can be provided to a beneficiary every year.

Gary Bevill, M.D., a family physician and practice owner of South Arkansas Medical Association in El Dorado, has been perfecting the delivery of this Medicare benefit to the patients in his six-physician practice for more than two years now.

Bevill told AAFP News that the clinic provides health care for nearly 2,000 Medicare patients and, in 2017, set a goal to complete 40 AWVs a week. According to practice administrator Pete Atkinson, M.H.A., that goal was recently exceeded.

Consider this: According to AAFP calculations based on national Medicare allowable amounts for a subsequent annual wellness visit, a practice with just 150 Medicare patients could generate an additional $17,500 annually.

So a practice like Bevill's has the potential to earn some significant money -- although, because of high overhead, not all of it will be profit. And for this practice, at least for the time being, all of those additional earnings are slipped right back into practice operations.

"We're reinvesting those dollars to improve our overall quality," said Bevill. For instance, some of that revenue goes toward paying the salary of the clinic's population health coordinator, an important member of the clinical team.

Bevill called his practice "forward-thinking" in its efforts to stay ahead of all the changes that have come with health care reform.

Resources Assist FPs With Medicare AWV

Physicians may need some help navigating the details of the Medicare annual wellness visit (AWV). Explore a new AAFP supplement(3 page PDF) offered by Family Practice Management (FPM) that walks physicians through a step-by-step approach to doing a Medicare AWV.

And be sure to visit the FPM content collection on AWVs that features a wide variety of articles related to this topic.  

He envisions an ongoing cycle of funding quality improvement that will lead to real profits in the future given his practice's participation in the Arkansas Aledade Accountable Care Organization, the experience gained in CMS' original Comprehensive Primary Care (CPC) initiative and the clinic's recent inclusion in CMS' new CPC Plus initiative.

"I love being a physician," said Bevill, who added that he's saddened by accounts of frustrated physicians ready to ditch their professional calling. To them, he offers encouragement: "You can change and thrive -- as I like to think we have done here with the Medicare annual wellness visit."

Caring for Patients

The AWV was introduced in January 2011 after passage of the Patient Protection and Affordable Care Act. The service is covered by one of two CPT codes -- G0438 for the initial visit and G0439 for a subsequent AWV.

Although a physical exam is not required during the visit, Amy Mullins, M.D., the AAFP's medical director of quality improvement, said there are specific components that must be covered. "The visit is prescriptive and the physician does have to participate," said Mullins. (Review the resources in the box on the right for specific details about AWV requirements.)

She described the visit as "having a conversation."

"This is time where you get paid to talk to your patient without doing an actual physical exam," said Mullins. Physicians often don't have time to discuss important topics such as home safety, how to take medications, implementing advance directives and reviewing the family support system, she added.

And if the patient wants to address a specific medical concern, "then you can add a CPT code modifier -25 and bill for two visits," said Mullins. (In this case, the patient may be responsible for a copay.)

In fact, Bevill's practice has achieved greater success in patient compliance when combining the AWV with an office visit. "We're in a rural part of Arkansas and a lot of our senior citizens only go to the doctor when they're sick," said Bevill. The concept of a well visit alone was a tough sell for some.

Cuenca stressed the emphasis on preventive care.

"You have this time blocked off, you get to know your patient, and you formulate a road map, a written care plan for the next five to 10 years. You make recommendations for preventive services that Medicare covers and that patients can utilize to prevent other medical conditions that increase health care costs," he said.

"In this one visit, you can capture pretty much everything if you organize it correctly and do it right using a team-based approached," Cuenca added.

Improving Quality

Cuenca schedules roughly 40 minutes to complete his portion of an AWV, but he considers it time well spent with his patients, as well as a significant boost toward achieving National Committee for Quality Assurance quality metrics and meeting Healthcare Effectiveness Data and Information Set( (HEDIS) measures.

HEDIS is a tool used by most of America's health insurance plans to measure performance across dimensions of care and service. Many of the HEDIS measures for older adults -- such as assessing fall risk and discussing physical activity -- count toward value-based payment, said Cuenca.

So at the same time physicians do a Medicare AWV, they can capture risk adjustment factor scores for patients with Medicare Advantage plans, said Cuenca. "That's another reason why it's important for physicians to start thinking about this."

For his part, Bevill noted the importance of hierarchical condition category (HCC) codes that Medicare uses to define risk and to predict the cost of patient care.

Every year, a Medicare patient's HCC score starts at zero and has to be rebuilt by adding codes back into the patient's record, said Atkinson. The AWV provides the best opportunity to update a patient's HCC score.

"That HCC score drives our goal in the ACO (accountable care organization) and potential shared savings, so it's very important," he said. "And in CPC+, that HCC score determines how much we get per member per month. So it's really important that number be accurate."

Should family physicians learn how to do AWVs? Cuenca is very clear: If physicians are not doing AWVs, they should be.

"You can do this Medicare wellness assessment, and at the same time, grab the opportunity to take care of chronic conditions, achieve metrics and even capture risk adjustment factor scores to take care of those high-risk patients."

Related AAFP News Coverage
MACRA: The Medicare Access and CHIP Reauthorization Act

More From AAFP
MACRA Ready: The Shift to Value-Based Payment

FAQ on the Medicare Annual Wellness Visit (AWV)