The Center for Medicare and Medicaid Services (CMS) has been pushing for reforms on how healthcare is delivered and paid for. Hence, Medicare has been incentivizing healthcare providers for providing value-based and patient-centered care programs to their eligible patients. One of these programs is Medicare’s Annual Wellness Visits (AWV), a preventative type of care, which is a free service for Medicare Part-B patients.
The Annual Wellness Visit (AWV) is designed as a yearly appointment with a primary care physician, physician assistant, or nurse practitioner to create or update a patient’s prevention plan. The goal is to prevent the onset of an illness based on the patient’s current health status and risk factors.
What is Annual Wellness Visits?
Medicare established the AWV benefit on January 1, 2011, under the Affordable Care Act. Apart from possibly detecting disease or cognitive impairment, AWV has been effective in reducing healthcare costs, engaging patients, and potentially opening doors for other Medicare services.
Annual Wellness Visits CPT
G0438: Annual wellness visit, contains a personalized prevention plan of service (PPS), initial visit
G0439: Annual wellness visit, has a personalized prevention plan of service (PPS), subsequent visit
G0468: Federally qualified health center (FQHC) visit, IPPE, or AWV; an FQHC visit that has an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and contains a specific pile of Medicare-covered services that would be provided per diem to a patient obtaining IPPE or AWV
Diagnosis code V70.0; Initial Annual Wellness Visit G0438; Next Annual Wellness Visit G0439
Medicare will pay a physician for an AWV service and a medically essential service, e.g. a mid-level set office visit, Current Procedural Terminology (CPT) code 99213, provided during a single beneficiary meeting. It is necessary that the components of the AWV not be replicated in the medically required service. Physicians must append modifier -25 (important, each identifiable service) to the medically required E/M service, e.g. 99213-25, to be paid for both services.
Annual wellness visit CPT code by age
In CPT, codes 99381–99397 for complete preventive evaluations are age-specific, starting with infancy and going through patients age 65 and over for both new and established office patients. Preventive medicine services can be symbolize in evaluation and management (E/M) codes section of CPT. These E/M codes may be reported by any qualified physician or other qualified healthcare professional, i.e. NP, APP or PA.
Annual wellness visit codes
AWV HCPCS Codes and Descriptors
G0438
Annual wellness visit; has a personalized prevention plan of service (PPS), initial visit
G0439
Annual wellness visit, has a personalized prevention plan of service (PPS), subsequent visit
G0468*
Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that contains an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and has a typical pile of medicare-covered services that would be provided per diem to a patient receiving an IPPE or AWV.
Diagnosis
Report a diagnosis code when offering an AWV claim. Since Medicare doesn’t need you to document a specific AWV diagnosis code, you may select any diagnosis code compatible with the patient’s exam.
Wellness visit vs annual physical
What is a “Welcome to Medicare” preventive visit?
People over 65 who prefer standard Medicare coverage (Part B-Medical coverage) when they register in Medicare can also opt for a one-time “Welcome to Medicare” preventive visit within the first 12 months. For this visit to be free:
- Your doctor must accept Medicare
- Your doctor must not supply additional tests or services during the exact visit
- Additional tests or services not covered under preventive benefits must not be conducted
When making your appointment, let your doctor’s office understand this is your “Welcome to Medicare” preventive visit. This visit will include a check of your medical history and counseling on your preventive benefits. It is not a complete Head-to-Toe Physical Assessment.
What is a Medicare Annual Wellness Visit?
If you select standard Medicare coverage, you can choose to have an Annual Wellness Visit (AWV) to develop a personalized prevention plan. In addition, cases such as advance care planning are examined. When making your appointment, let your doctor’s office know this is your “Annual Wellness Visit.” Like the “Welcome to Medicare” visit, it is not a complete Head-to-Toe Physical Assessment. Your AWV is covered if you have been registered in standard Medicare coverage (Part B) for more than 12 months and you have not obtained another AWV in 12 months. Over the period, your personalized prevention plan will be corrected based on our current health and risk factors.
What is an annual physical exam, and does Medicare Advantage cover this?
An annual physical exam is more comprehensive than an AWV. It involves a physical exam by a doctor and contains bloodwork and other tests. The annual wellness visit will just contain corresponding routine measures such as height, weight, and blood pressure. An easy way to recognize the distinction is that a Medicare wellness exam will include assessments, but won’t include physical tests where the doctor has to physically examine you unless you have a specific diagnosis or sign. A Medicare Advantage plan will provide you entrance to both the “Welcome to Medicare” preventive visit and the Medicare AWV. Most of the time, a Medicare Advantage plan will cover annual physicals free of charge.
Importance of annual wellness visits
Wellness visits enhance provider-patient relationships.
Ever visited a provider for the first time during acute illness and felt a little out of place or unsure? Annual wellness visits are the chance to have open, honest, and genuine conversations with your provider about your health and lifestyle before you’re sick. When you visit the same provider for all of your medical conditions, you establish a relationship. Good relationships between patients and providers are helpful for the patient’s health.
Wellness appointments allow you to take control of your health and healthcare.
An open conversation with your provider helps you take control of your health. This is your opportunity to manage problems you have that may not be noticed through a physical exam or assessment of your health history, like a mental health illness. Wellness visits are an ideal time to get help with a problem like anxiety or depression.
Documentation Requirements for Initial Medicare Annual Wellness Visit
- Health risk assessment
- Medical history
- Current providers and suppliers
- Measurements
- Cognitive function
- Potential risk factors for depression
- Functional ability and safety
- Written screening schedule
- Risk factors and conditions
- Health advice and referrals
- Advance care planning services (upon request)
Documentation Requirements for Subsequent Medicare Annual Wellness Visits
The documentation requirements for subsequent annual wellness visits:
- Update the HRA
- Update the beneficiary’s medical and family history
- Update the list of current healthcare providers and suppliers
- Document the routine, essential measurements
- Assess cognitive function
- Examine depression and risk factors
- Update reported screening schedule
- Update risk factors and conditions for which interventions are suggested
- Update the prevention plan of service, including personalized health advice and referrals to health education and/or preventive counseling services or programs, as appropriate
- Inspection/discuss advance care planning services, at the patient’s discretion
Billing for annual wellness visit
Medicare Part B covers an AWV if committed by a:
- Physician (a Doctor of Medicine or Osteopathy)
- Qualified Non-Physician Practitioner (NPP) (a Physician Assistant [PA], Nurse Practitioner [NP], or Certified Clinical Nurse Specialist [CCNS])
- Medical professional (including a health educator, registered dietitian, nutrition professional, or another licensed practitioner), or a team of medical experts presently headed by a physician
When you supply an AWV and a significant, individually identifiable, medically required Evaluation and Management (E/M) service, Medicare may pay for the additional service.
You can only bill G0438 or G0439 once in 12 months. G0438 is for the first AWV and G0439 is for subsequent AWVs. Remember, you must not bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. Medicare rejects these claims of “Benefit maximum for this period or occurrence has been reached” and “Consult plan benefit documents/guidelines for information about limitations for this service.”
AWV, IPPE, and Routine Physical
IPPE
The IPPE, understood as the “Welcome to Medicare” preventive visit, encourages good health through disease prevention and detection.
Medicare spends 1 patient IPPE per lifetime not after the first 12 months behind the patient’s Medicare Part B helps eligibility date.
Medicare pays the IPPE charges if the provider takes the assignment.
AWV
Medicare conceals an AWV that provides Personalized Prevention Plan Services (PPPS) for patients who:
- Aren’t within 12 months after the patient’s first Medicare Part B uses eligibility date
- Didn’t get an IPPE or AWV within the past 12 months
- Medicare spends the AWV costs if the provider takes the assignment and the deductible doesn’t apply
Routine Physical Exam
Exam conducted without connection to treatment or diagnosis for a typical illness, symptom, complaint, or injury
- Medicare doesn’t protect the routine physical; it’s forbidden by statute, but Medicare includes some features of a routine physical under the IPPE, the AWV, or other Medicare benefits
- The patient pays 100% out-of-pocket
How is AWV conducted?
First, the provider will ask the patient to answer the Health Risk Assessment (HRA) questionnaire. This part is crucial in aiding the provider in creating a personalized prevention plan.
The visits will most likely cover the following:
- Medical record and family history
- Review of current providers and their prescriptions
- Routine measurements like height, weight, and blood pressure
- Personalized counseling
- Risk factors and treatment options
- A checklist of needed preventive services.
- Advanced care planning
The provider may also perform a cognitive assessment to identify impairment. It could be through direct observation and based on information provided by the patient, family members, or caregivers. In the event that an impairment is detected, Medicare will cover a separate visit for a more thorough assessment that includes checking for signs of dementia, Alzheimer’s, anxiety, or depression.
Who is eligible?
Eligible patients are those receiving Medicare part B benefits for at least 12 months without any initial preventive physical examination like the one-time “Welcome to Medicare” preventive visits or an AWV within the past 12 months. Medicare will pay for an AWV once every 12 months with no co-payments or a Part B deductible unless the provider performs additional tests and services no longer covered by the benefit.
AWV is not to be confused with a head-to-toe physical examination. It is a preventive visit where the patient discusses problems with a clinician with the goal of staying healthy and away from hospital visits. The structure of an AWV provides enough time for the patient and the care team to discuss health-related matters not often covered during a physical exam, which is why this visit can last about 45 minutes.
What makes the AWV unique is its ability to close gaps often overlooked in regular office visits like a falls risk assessment or a dementia screening. The advanced care planning that the care team provides also covers living wills and advanced instructions from the patient. It is documenting the care plan that can be used when the patients could no longer express their medical wishes.
Yet, despite these benefits, AWV remains to be an underutilized Medicare benefit that is crucial in providing patient-centered care. A 2018 study published in the Journal of Health Affairs reported that only less than 20% of qualified Medicare patients have availed themselves of AWVs. More than 50% of primary care physician practices have not offered AWVs to their eligible patients.
Why is AMV underused?
1. Lack of awareness
AMW is not maximized primarily because both the provider and patient are not aware of it, which is often the case with most Medicare programs.
2. Complex requirements
For providers who are aware, the complexity of the requirements before a provider can bill dissuades them from further investing and participating in the program.
3. Additional burden
Providers may think that dedicating 30 minutes to one hour of their precious time to perform preventative examinations is an additional burden they can no longer afford to do.
4. Lack of resources
Primary care providers may not have the tools, capabilities, and infrastructure to effectively engage and communicate with patients.
How to overcome AWV adoption barriers?
The benefit to both patient and provider is clear when it comes to optimizing patient care with AWV through prevention and early detection of disease or disability. A review of claims data of AWV paints a clearer picture of how this benefit can potentially reduce costs for taxpayers too. Consider the average annual cost benchmark for an eligible beneficiary, which is $10,000. Once the patient receives an AWV, the cost burden is reduced by 5.7%, which is substantial, and not many value-based care models can outperform.
Hence, it is imperative that primary care providers should begin providing this benefit to all their eligible patients through the following strategies:
1. Awareness campaign
Eligible patients will most likely opt-in once they are made aware that an AWV will provide them with personalized care and prevent them from visiting their doctors frequently. Providers can leverage in-person visits to introduce and thoroughly explain the benefits of the program as well as answer any questions the patients may have.
In this way, providers can readily address another common barrier to AWV, which is how to engage patients with a benefit that they do not perceive as treating their most pressing concerns outright. A patient dealing with a serious medical condition will assuredly receive the appropriate treatment and an AWV will be beneficial in preventing the onset of other health issues. For instance, a patient suffering from multiple complex chronic conditions can avail of Medicare’s Chronic Care Management (CCM) services and also an AMW once every 12 months.
Meanwhile, an outreach campaign can be conducted by sending letters or emails to all qualified patients with an invitation and an explanation of the benefits of the program. This could also be done through phone calls for a more personalized approach. The only drawback to this strategy is that a practice needs to allot time and assigned personnel to conduct these campaigns.
2. Outsourcing the service
For physicians not to be burdened because of the immense time and resources required by AMW, the most practical solution is to outsource the service to a credible third-party provider. There are vendors that can tailor AWV services according to the preferences and needs of the practice. In this way, practices can fully maximize their revenues while optimizing patient care with AWV.
There are different ways to outsource. One is through technological or software-only solutions where the care services are offered via the web only. There are plug-ins that can be incorporated into the EHR where the provider’s staff can automate and streamline the procedures and documentation. There is also the full-service provider that can perform the AWV by bringing in additional staff and the software. A full-service option will offer more flexibility for providers by freeing them from any additional burden and enabling them to focus on their core competencies like developing a good insight into their patient’s health.
Ascent Care Partners (ACP) is a virtual healthcare provider offering turnkey Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) solutions as well as Behavioral Health Integration (BHI), Principal Care Management (PCM), and Annual Wellness Visits (AWV). We help physicians’ practices realize deserved revenue with no overhead cost, risk, or upfront payment. We enable practices to optimize their patient care and see their business grow.
