Medicare coverage is available for an Annual Wellness Visit (AWV) providing Personalized Prevention Plan Services (PPPS). The AWV must be provided by a physician; a qualified non-physician practitioner such as a nurse practitioner, a physician assistant, a certified clinical nurse specialist; a medical professional including a registered dietitian, health educator, nutrition professional or other licensed practitioner; or a team of such medical professionals working under the supervision of a physician.
Who is Eligible for AWV?
Enrollees in original Medicare or a Medicare Advantage (MA) plan are eligible for these services, provided they receive the service from an in-network provider. The AWV includes an HRA or a Health Risk Assessment as well. With the introduction of the Affordable Care Act, Medicare provides more preventive and wellness care benefits to enrollees. From Medicare’s point of view, these benefits are intended to keep beneficiaries healthy rather than paying for particular treatments when they get sick. Beneficiaries also get to save money by eliminating co-insurance, copayments and deductibles for a number of services. (Coverage for AWV is provided as Medicare Part B benefit.) Both the coinsurance/copayment and the Medicare Part B deductible are waived for the annual wellness visit.) The AWV is utilized to develop a personalized prevention plan for the beneficiary. After the initial AWV, enrollees are eligible for a follow-up visit every 12 months.
AWV vs. Welcome to Medicare Exam
AWV is distinct from the Welcome to Medicare exam that is available for new beneficiaries within the first year of enrollment in either original Medicare or Medicare Advantage Plan. This exam comprises a review of patient family and medical history and an examination of vital signs and measurements. Prior to the Affordable Care Act, Welcome to Medicare was the sole preventive exam that was covered by Medicare. Moreover, Medicare did not cover any routine annual follow-up visits. AWV comprises more services such as the chance to develop a personalized prevention plan, provide a cognitive function checkup and review the care the person is receiving from other doctors.
New Medicare enrollees have to wait 12 months after their Welcome to Medicare Physical before they can receive the AWV benefit. While the AWV does not require the enrollee to share the costs, if the provider treats an existing condition or one that is diagnosed during the visit, the enrollee has to pay for those services. Typically, clinical laboratory tests are not covered in the AWV, but the provider can make referrals for such tests as part of the annual wellness visit, if appropriate.
Components of the Annual Wellness Visit
- For the first AWV providing PPPS
- Acquiring the history of the beneficiary
- HRA or Health Risk Assessment
- Establishment of beneficiary’s family and medical history
- Reviewing the potential risk factors the beneficiary may have such as depression, and other mood disorders
- Reviewing the beneficiary’s functional ability and level of safety
- Beginning evaluation
- Measuring height, weight, BMI, blood pressure and other routine measurements considered appropriate
- Making a list of current providers and suppliers
- Diagnosis of any cognitive impairment the beneficiary may have
- Counseling the beneficiary
- Preparing a written screening schedule for the beneficiary
- Identifying a list of risk factors/conditions for which the primary, secondary or tertiary interventions may be recommended or underway for the beneficiary
- Providing personalized health advice to the beneficiary and a referral as required for preventive counseling services or health education.
- Acquiring the history of the beneficiary
The subsequent Annual Wellness Visits to provide PPPS comprise updates on the above listed components.
Medicare Part B Preventive Services
- IPPE or Initial Preventive Physical Examination – those qualifying for AWV are no longer eligible for IPPE
- Bone mass measurements
- Colorectal cancer screening
- Cardiovascular screening blood tests
- Diabetes screening tests
- Diabetes self management training (DSMT)
- Counseling to prevent tobacco use for asymptomatic patients
- HIV (Human Immunodeficiency Virus) screening
- Glaucoma screening
- IBT for cardiovascular disease
- MNT (Medical Nutrition Therapy)
- IBT (Intensive Behavioral Therapy) for obesity
- Seasonal influenza, pneumococcal, and Hepatitis B vaccinations and their administration
- Prostate cancer screening
- Screening for depression in adults
- Screening and behavioral counseling interventions in primary care to reduce alcohol abuse
- Screening pap tests and pelvic examination
- Screening mammography
- Ultrasound screening for abdominal aortic aneurysm
- Sexually transmitted infections (STIs) Screening and High Intensity Behavioral Counseling (HIBC) to prevent STIs
Medical Billing for AWV
G-codes for filing AWV claims
When filing claims for AWV, use the following HCPCS (Healthcare Common Procedure Coding System) codes:
- G0438 : Annual wellness visit; includes a Personalized Prevention Plan of Service (PPPS), initial visit
- G0439 : Annual wellness visit; includes a Personalized Prevention Plan of Service (PPPS), subsequent visit
Note the following:
- AWVs can be for either new or established patients, because the code does not make a distinction between the two. G0438 signifying the initial AWV is performed on patients who have been enrolled with Medicare for more than a year. Patients are eligible for their subsequent AWV signified by G0439, one year after their initial AWV visit.
- During the first year a patient has enrolled with Medicare, he/she is eligible for the IPPE (Initial Preventative Physical Exam) or Welcome to Medicare visit. This exam is reported using the code G0402. For such a patient, do not use the G0438 code.
Procedural and Diagnostic Codes to be Used to Report AWV
A significant, separately identifiable, medically necessary Evaluation and Management Service signified by CPT codes 99201 – 99215 billed at the same visit as the AWV is likely to be reimbursed by Medicare when billed with modifier – 25. Services such as an EKG (electrocardiogram) can be billed on the same date of service as the AWV if it is medically necessary. Services provided must be medically necessary to treat the beneficiary’s injury/illness or to improve the functioning of a body part. The copayment/coinsurance and deductible can apply for these services.
Providers can choose any appropriate diagnosis code, though CMS does not require a specific diagnosis code for the AWV.
Medicare will not cover ultrasound screening for AAA that is ordered based on an AWV referral for a beneficiary who has never had an IPPE. This service is covered by Medicare only if the beneficiary meets certain eligibility requirements including a referral received with an IPPE.
CMS recommends that providers check with their MAC (Medicare Administrative Contractor) to find out what options are available to verify the eligibility of a beneficiary for AWV and other preventive services. This would help to ensure whether or not the beneficiary has already received his/her first AWV from another provider and thereby understand whether to bill for a first or subsequent AWV.
Improve Practice Revenue with AWV
Providers can bill for the AWV along with an E/M visit by adding the appropriate G-code to their claim. By doing this, their average collection rate of $70 for a 99213 visit can increase to more than $200. When the AWV exam is performed by a member of the care team such as a medical assistant under the supervision of the physician, the reimbursement value is increased further.
Physicians can take advantage of the bonuses available with select MA (Medicare Advantage) plans, when providing the AWV. MA plans are expected to demonstrate an increase in quality services over standard Medicare or else will be subjected to stiff penalties under ACA. (CMS’ Star Ratings for MA plans are available on the Medicare.gov website.)
MA plans will be rated in five performance domains comprising 37 measures for the contract year 2013. These domains are:
- Staying healthy: screenings, vaccines and tests (10 measures)
- Managing chronic conditions: long-term condition management (13 measures)
- Member experience: satisfaction with the health plan (6 measures)
- Member complaints: difficulties in accessing services and improvement in plan performance (4 measures)
- Customer service: performance of the plan (4 measures)
These plans are also rated on the basis of Part D prescription drug benefits. Data from various sources such as Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, Healthcare Effectiveness Data and Information Set (HEDIS), Health Outcomes Survey, CMS data and prescription drug event data is used for the evaluation. MA plans face considerable pressure to improve their star ratings which is done by improving provider documentation and reporting. Consequently, these plans are offering significant bonuses to providers to submit documentation for clinical data capture that is in line with the Medicare AWV requirements.
For physicians, AWV not only helps to promote the health and well being of their patients but also acts as an excellent source of revenue. The average reimbursement for the initial AWV (G0438) is approximately $166 and the subsequent AWV (G0439) is approximately $111. Physicians have a number of Medicare patients in accordance with which the revenue flow will increase. In addition, providers can also bill for additional services, screenings, treatments and tests for chronic conditions diagnosed during the wellness visit. Medicare reimburses a number of screenings, tests, treatments and services that are provided during the AWV or another E/M visit.
The important thing for providers to keep in mind is that AWV must be billed accurately. Inappropriate coding will be severely penalized by CMS audits that have been launched under CMS’ RAC (Recovery Audit Contractor). All documentation must be accurate and complete with no loose ends and ambiguities. For providers looking for the smooth functioning of their practices, patient well being, good reputation and steady revenue, the practical option is to have a seasoned medical billing company with its professional team of medical billers and coders to take care of the billing cycle. Insurance eligibility verification is among the services provided by a medical billing firm, which will help determine whether the patient is eligible to receive the services provided.