FAQ on the Medicare Annual Wellness Visit

FAQ on the Medicare Annual Wellness Visit (AWV)

Frequently Asked Questions: Medicare’s Annual Wellness Visit and Initial Preventive Physical Examination/Welcome to Medicare Preventive Visit

Why should I consider implementing Medicare’s Annual Wellness Visits?

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.  

Is there a difference between the Initial Preventive Physical Examination/Welcome to Medicare Preventive Visit and the AWV?

Yes. 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.

Can the IPPE be done if 12 months have elapsed since enrollment in Medicare Part B?

No. Patients are only eligible within the first 12 months of Medicare Part B enrollment for an IPPE/Welcome to Medicare Preventive Visit.

Is the AWV the same as an annual physical exam?

No. The AWV does not replace a complete head-to-toe physical exam. A yearly physical (Codes: 99381-99397) is never a covered service.

What is the cost to the beneficiary?

The AWV is covered 100% by Medicare. There is no deductible or coinsurance owed by the patient.

What information is necessary to educate the beneficiary?

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.

Can the patient complete any portion of the AWV?

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. Family Practice Management (FPM) has several patient surveys and questionnaires for patients and/or your staff to complete.

What steps does my practice and patient take to complete the components of the AWV?

1. Administer a health risk assessment (HRA). Access a health risk assessment and other patient surveys and questionnaires at the AAFP’s Family Practice Management (FPM). 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 five to 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.

What steps does my practice take to complete the components of the IPPE?

1. Review the medical and social history. At a minimum, collect information about:

  • Past medical and surgical history;
  • Current medication(s) and supplement(s);
  • Family health history with a review of medical events in the beneficiary’s family, including diseases that may put the beneficiary at risk;
  • History of alcohol, tobacco, and illicit drug use;
  • Diet; and
  • Physical activities.

2. Review the potential risk factors for depression and other mood disorders.

3. Review the beneficiary’s functional ability and safety.

  • Use the appropriate screening questions or standardized questionnaires recognized by national professional medical organizations. At a minimum, review:

4. Examine, obtain, and discuss:

  • Height, weight, body mass index (BMI), and blood pressure;
  • Visual acuity (Snellen chart or distance test);
  • Other factors deemed appropriate based on the medical, social history, and current clinical standards;
  • End-of-life planning (either verbal or written) containing:
    • The beneficiary’s ability to prepare an advance directive in case of injury or illness that causes the beneficiary to be unable to make health care decisions; and
    • Whether you are willing to follow the wishes expressed in the advanced directive. As of 2016, advanced care planning (ACP) is a separate reimbursable benefit. Additional ACP resources are available from the AAFP.  

5. Educate, counsel, and refer the patient based on the components of the IPPE.

6. Educate, counsel, and refer the patient for other preventive services.

  • Write a brief plan (or checklist) for the beneficiary to obtain, which may include:
    • A once-in-a-lifetime screening electrocardiogram (EKG/ECG) (Code: G0403); and
    • Other appropriate screenings and preventive services covered by Medicare.

Who 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).   

What codes are used to file claims?

  • 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)

How do I bill for the yearly physical exam and AWV?

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. The AWV can be an ongoing source of revenue once the beneficiary becomes eligible after the first 12 months of Medicare Part B enrollment (initial AWV), as well as on an annual basis (subsequent AWV) thereafter.

Can evaluation and management (E/M) services be provided the same day as the AWV?

Yes. The appropriate E/M service may be billed in addition to the AWV. Report the Current Procedural Terminology (CPT) code with modifier -25. The E/M service is subject to a co-payment.

Does the patient need to sign a consent form for the AWV or IPPE?

No consent form is required for this benefit.

What happens if another provider files a Medicare AWV?

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.

How can I check a Medicare patients’ billing history to see whether or not they have received an AWV within the past 12 months, so I know whether Medicare will cover the AWV I am about to provide?

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 spends 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 to you at any time with limited functionality outside of normal business hours, at no cost.

Last updated: February 2017