What You Need to Know About Annual Wellness Visits for Medicare Patients

Many primary care practices wanted to avoid providing the Welcome to Medicare Visit and the Annual Wellness Visits.  The visits don’t correspond to what most physicians consider as an annual physical exam, as described by preventive medicine codes 99381—99397.  In fact, although Medicare’s booklet, “Medicare and You” tells Medicare beneficiaries they are eligible for an “exam” each year, neither of these visits has much of an exam component required.   Although groups have resisted them, patients expect them.

The Welcome to Medicare Visit, or Initial Preventive Physical Exam (IPPE) was a gift of the Medicare Modernization Act of 2004.  Newly enrolled Medicare beneficiaries are eligible for this once-in-a-lifetime benefit during the first twelve months they are enrolled in Medicare.  The Welcome to Medicare visit (code G0402) requires:

• Taking the patient’s medical, social and family history, including the use of vitamins and supplements
• Review of individual’s potential for depression using an industry standard screening tool
• Review of the patient’s functional ability and level of safety, using a standard tool
• Physical exam to include height, weight,  BMI calculation, blood pressure, and visual acuity
• Performance and interpretation of an EKG—optional (Use code G0403 for the screening EKG, not 93000)
• With patient permission, end of life planning
• Education, counseling and referral, as appropriate, based on the results of the first five elements
• Education, counseling, and referral including a brief written plan given to the patient (such as a checklist) recommending the appropriate screening and other preventive services covered by Medicare.
• Any diagnosis is acceptable for codes G0402 or G0403.

The Initial and Subsequent Annual Wellness Visits (AWV)  were Healthcare Reform Act mandates, and the benefit became effective January 1, 2011.  Starting in 2012, these visits must include a Health Risk Assessment, completed before or as part of the AWV.   Patients are eligible for the initial AWV if they have been enrolled in Medicare for over a year, and they have not received an IPPE or AWV in the past year.  A patient may receive a subsequent AWV one year after the initial AWV.  The requirements for an Initial Annual Wellness Visit (G0438) are:

• Reviewing the patient’s self-administered Health Risk Assessment
• Taking or updating individual’s medical and family history
• Establishing a list of current providers and suppliers of medical care
• Height, weight, BMI calculation (or waist circumference), BP and “other routine measurements as deemed appropriate”
• Detection of any cognitive impairment that the individual may have by direct observation, with consideration of information from medical records, patient reports, or concerns raised by family members
• Review potential for depression based on use of appropriate screening instrument
• Review of individual’s functional ability and level of safety based on direct observation, or use of screening questionnaire
• Establishment of a written screening schedule, such as a checklist, for the next 5-10 years based on the recommendations of the US Preventive Task Force and Advisory Committee on Immunization Practices, and the individual’s health status, screening history, and age-appropriate covered Medicare services
• Development of a list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway, including mental health conditions or risk factors or conditions identified through an previously performed Welcome to Medicare Visit (or this visit) and a list of treatment options and their associated risks and benefits
• Furnishing of personalized health advice and referral, as appropriate to health education or preventive counseling programs aimed at reducing identified risk and improving self management including weight loss, smoking cessation, fall prevention and nutrition.

Looking at the list of requirements, it is no wonder practices are reluctant to perform it!  However, the primary care specialty societies have developed templates for their members’ use, which has simplified the process. Links: AAFP, ACP (Editor’s Note: Requires password, but if you cancel, you’ll get the form).

The subsequent AWV (G0439) requires updates to the same components as in the initial exam. Because the bulk of the work was done at the initial visit, the subsequent visit is less time consuming.

A few other key points: these visits are not defined as new or established.  There is no co-payment or deductible for the AWV.  The deductible applies to the IPPE, but not co-insurance.  A physician practice will need to check with their Medicare Advantage plans to see if they cover preventive medicine services as defined by CPT or these visits.  In addition to the AWV, a practice may bill for a pelvic and breast exam G0101.  A problem-oriented visit may also be billed on the same day; however, CMS tells us that no part of the documentation used for the AWV may be used in determining the level of service for the  office visit.

AWV chart from CMS can be downloaded from the CMS site.

Betsy Nicoletti, M.S., CPC, is the founder of Codapedia.com, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at www.mpconsulting.org. You can watch an informational video by Betsy Nicoletti on Better Collections Through Improved Medical Coding now. Or, view her archived webinar on What You Can Do to Prepare for Medicare Payment Reductions. She has also written recently on Why Can’t We Get Paid? A Look at Denials.