Medicare Wellness and Care Coordination Services

Providing Medicare wellness and care coordination services such as annual wellness visits, chronic care management, advance care planning, and transitional care management allow your practice to:

  • Optimize fee-for-service revenue
  • Improve quality
  • Decrease total cost of care.

These services may also help financially support other population health management initiatives.

Medicare Wellness

Annual Wellness Visits (AWV) -- The AWV offers an opportunity for a patient to partner with their physician to focus on preventive screening and wellness. The creation of a personalized prevention plan created for the beneficiary is a way to improve patient engagement.

Medicare Care Coordination

Chronic Care Management (CCM) -- Family physicians and other eligible health care professionals can be reimbursed by CMS for providing CCM services to their Medicare patients who have two or more chronic conditions that are expected to last at least 12 months.

Transitional Care Management (TCM) -- Two CPT codes are used to report TCM services and are designed to pay for services provided to Medicare beneficiaries whose medical and/or psychosocial problems require moderate- or high-complexity medical decision making during transitions in care from a hospital or other health care facility to a community setting (e.g., home, rest home, assisted living).

Advance Care Planning (ACP) -- ACP is the face-to-face time a physician or other qualified health care professional spends with a patient, family member, or surrogate to explain and discuss advance directives. Two CPT codes are used to report ACP services: 99497 and 99498.

Side-by-Side Comparison of Medicare Wellness and Care Coordination Services

Financial Importance
Financial Importance: AWV
Financial Importance: Initial Preventive Physical Exam (IPPE) G0402 - $169*                                       

Initial AWV G0438 - $175*                                

Subsequent AWV
G0439 - $119*

Supports patient assessment, patient-directed goal setting, and development of a comprehensive care plan.

The AWV is 100% covered—no copay nor deductible for eligible beneficiaries     

Monthly payment opportunity
CPT code 99490 - $43*             

Non-complex CCM
20-minute timed service provided by clinical staff to coordinate care across providers and support patient accountability

CPT Code 99487 - $94*            

Complex CCM
60-minute timed services provided by clinical staff to substantially revise or establish moderate to high-complexity decision making

G0506 (Add on code to initiating AWV/IPPE or comprehensive evaluation and management [E/M] visit) - $64

Initiating chronic care by a comprehensive assessment and care planning by physician or ARNP/PA during office visit, AWV, or when CCM is initiated. Requires the development of a care plan by the practitioner.

This may only be billed once.

CPT code 99497 - $86*
First 30 minutes (minimum 16)

CPT code 99498 -  $76*
Add-on for additional 30 minutes

Opportunity to discuss patient and caregivers’ wishes concerning end-of-life care

No copay for Medicare beneficiaries if done during AWV
CPT code 99495 - $167*
Moderate to high complexity

CPT code 99496 - $236*
High complexity

Sets up a safe and successful patient transition from a hospital or other health care facility to a community setting

Operational Advantages
Operational Advantages: AWVCCM
Operational Advantages: AWV helps with empanelment and attribution of Medicare beneficiaries

Establishes or strengthens rapport with the patient and/or caregiver

Chance to introduce TCM, CCM, and ACP to the patient
Reduces telephone calls to the practice by developing a regular communication channel for CCM patients

Regular monthly payment will support additional clinical staff hours or positions

Time for staff to provide patient education and answer medical questions
No limit on the number of times ACP can be billed for a given beneficiary during a given time period

Opportunity for patient to communicate and/or document wishes for family

Increased patient engagement and satisfaction in their care
Increases patient satisfaction by reducing risk of readmission by improving care and meeting patient’s needs

Service requires face-to-face visits with primary care provider and team in 14 days for moderate complexity (99496) or 7 days for high complexity (99495)

Prompt follow up decreases unnecessary readmissions and reduces total cost
Clinical Outcomes
Clinical Outcomes: AWVCCMACPTCM
Clinical Outcomes: Improves quality of care by identifying and closing care gaps and developing a care plan

Provides overall assessment and plans personalized preventive needs and early interventions

Opportunity to update the clinical record to reflect current problem list and diagnosis coding for hierarchal condition category (HCC) risk scoring and risk stratification

Planning access to needed care will decrease emergency room visits and hospitalizations and drive down cost
Decreased hospitalizations/emergency room (ER) visits will decrease cost of care through prevention and early intervention
Improved follow through and implementation of personalized care plan Increasing dedicated staff time will close care gaps

Improves communication and care coordination across health care professionals and settings

Improves patient engagement and accountability with regular communication with care team

Decisions on end-of-life care are documented in the medical record

Likelihood patient and/or caregiver’s wishes for end-of-life care will be upheld

May decrease total cost of care since patients may opt for palliative care options in a home setting instead of costly invasive, aggressive, or health facility choices

Improved continuity of care through:

Medicine reconciliation and answering beneficiary/caregiver questions to support safe and successful transitions

Review of hospital and pending diagnostic tests/treatments ordered

Improved coordination across the medical community

Establishing or reestablishing referrals with community providers/services to support patient’s behavioral health or health-related social needs

* Medicare and Medicare Advantage payment varies by geographical location. Check with your local Medicare Administrative Contractor (MAC) or plan for local/contracted rates. Values from Medicare Physician Fee Schedule 2018.
** Many Medicare Advantage plans will not pay for Chronic Care Management separately as monthly care management support includes this service.

Different Approaches to Help Your Practice Get Started 

Annual Wellness Visits

  • AWV 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 those patients which the staff has identified as highest risk (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 (HCC) and risk of high-cost care

Learn more about AWV.

Chronic Care Management

  • Identify Medicare Part B patient with at least two or more chronic conditions expected to last 12 months or until the death of the patient
  • Prioritize patients at highest risk of hospitalization or have recently been/are regularly seen in the ER
  • Start with patients that regularly call into the clinic to manage symptoms or with medical questions
  • Identify patients that may be mostly likely to benefit from care management based on the number of specialists involved in their care or who have limited social or local family support
  • Identify patients dual eligible for traditional Medicare and Medicaid (not managed Medicaid), or with secondary insurance coverage
  • Identify volume needed to hire additional part-time or full-time staff and then prioritize eligible patients

Learn more about CCM.

Advance Care Planning

  • Identify patients and families in which you have a strong rapport
  • Start with patients scheduled for AWV (no patient copay if offered with AWV)

Learn more about ACP.

Transitional Care Management

  • Identify hospitals and emergency departments (EDs) responsible for the majority of patients’ hospitalizations. With the shared goal of decreased readmissions, develop a relationship with those hospitals to improve timeliness of notification so the practice can reach out to patients within two working days of discharge
  • Add this service to decrease cost of care by reducing unnecessary readmissions
  • Add this service after AWV and CCM as the volume and associated revenue of this service is hard to anticipate

Learn more about TCM.