Annual Wellness Visit (AWV) refers to an appointment done yearly with a primary care provider (PCP) to create as well as update a personalized prevention plan to prevent illness based on your current health and risk factors. Primary care physicians can rely on reliable medical billing services to get these annual visits billed for reimbursement.

Medicare covers an AWV providing Personalized Prevention Plan Services (PPPS) for beneficiaries who are no longer within 12 months after the eligibility date for their first Medicare Part B benefit period, and who have not had either Initial Prevention Physical Examination (IPPE) or an AWV within the past 12 months. Coverage is provided for only one first AWV per beneficiary per lifetime and one subsequent AWV per year thereafter. Medicare does not cover routine physical examinations.

Medicare Part B covers an AWV if it is performed by a physician, qualified non-physician practitioner or a medical professional. For AWV, the patient pays nothing if the provider accepts the assignment.

AWV Documentation Requirements

To bill AWV, practices have to follow these 11 steps the first time a patient has an AWV-

  1. Carry out a Health Risk Assessment (HRA), which involves getting self-reported information from the beneficiary, getting details on demographic data, self-assessment of health status, psycho social risks, behavioral risks and more.
  2. Create the beneficiary’s medical and family history by documenting medical events of the beneficiary’s parents, siblings, and children, past medical and surgical history, and use of medications and supplements. CMS also encourages providers to pay close attention to opioid use during this part of the AWV, which includes Opioid Use Disorders (OUD).
  3. Make a list of current beneficiary providers and suppliers that regularly provide medical care.
  4. Measure height, weight, BMI, and blood pressure as well as other routine measurements deemed appropriate based on medical and family history
  5. Identify any cognitive impairment the beneficiary may have, by assessing their cognitive function along with considering information from beneficiary reports and concerns raised by family members, friends, caregivers, and others.
  6. Review their potential risk factors for depression, including current or past experiences with depression or other mood disorders by using any appropriate screening instrument.
  7. Assess the beneficiary’s functional ability and level of safety such as fall risk and hearing impairment through direct observation or by selecting appropriate questions with available or standardized screening questionnaires.
  8. Create an appropriate written screening schedule for the beneficiary, such as a checklist for the next 5 to 10 years based on the beneficiary’s HRA, health status and screening history, and age-appropriate preventive services Medicare covers.
  9. Set up a list of beneficiary risk factors and conditions including mental health conditions such as depression, substance use disorder, and cognitive impairment, risk factors or conditions identified through an IPPE and treatment options and their associated risks and benefits.
  10. Provide the patient with personalized health advice to reduce health risks and promote self-management and wellness such as fall prevention, weight loss and nutrition. Also offer appropriate referrals to health education or preventive counseling services or programs.
  11. Based on beneficiary’s judgment, provide advance care planning services including discussion about future care decisions, caregiver identification as well as explanation of advance directives, which may involve the completion of standard forms.

After the beneficiary’s first AWV, practices must review and update HRA and all other steps discussed above.

Medical Codes for AWV

HCPCS codes to file claims for AWVs are –

  • G0438 Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit
  • G0439 Annual wellness visit, includes a personalized prevention plan of service(PPS), subsequent visit
  • G0468 Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV

Medically necessary Evaluation and Management (E/M) service provided along with the AWV can be reported with additional CPT code with modifier -25.

Advance Care Planning (ACP) provided at the time of the AWV, at the beneficiary’s discretion can be documented using CPT codes –

  • 99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
  • 99498 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Coders are also advised to use any diagnosis code consistent with the beneficiary’s exam.

Medical coding companies providing documentation support for AWV must note that Medicare waives both the coinsurance and the Medicare Part B deductible for ACP when it is provided on the same day as the covered AWV, or furnished by the same provider as the covered AWV, billed with modifier – 33 (Preventive Service), or if it is billed on the same claim as the AWV.