annual wellness visit medicare code

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Medicare’s Annual Wellness Visit (AWV)

The Medicare Annual Wellness Visit (AWV) is a yearly appointment with a health professional to identify health risks and help reduce them and to create or update a personalized prevention plan. During a Medicare AWV, health professionals should also review any current opioid prescriptions, detect any cognitive impairment, and establish or update medical and family history.

Coding and Billing a Medicare AWV

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 IPPE or AWV

Diagnosis code V70.0; Initial Annual Wellness Visit G0438; Subsequent Annual Wellness Visit G0439

Medicare will pay a physician for an AWV service and a medically necessary service, e.g. a mid-level established office visit, Current Procedural Terminology (CPT) code 99213, furnished during a single beneficiary encounter. It is important that the elements of the AWV not be replicated in the medically necessary service. Physicians must append modifier -25 (significant, separately identifiable service) to the medically necessary E/M service, e.g. 99213-25, to be paid for both services.

For example, for the patient who comes in for his Annual Wellness Visit and complains of tendonitis would be billed as follows: CPT ICD9, G0438 V70.0, 99212-25 726.90 (tendonitis)

ACP Tools for the Annual Wellness Visit

The following forms and templates can be customized for use in your practice:

Practice Checklist
Patient Letter and Checklist
Health Risk Assessment :
View a paper version
View an electronic version from HowsYourHealth.org
Women's Prevention Plan
Men's Prevention Plan
Adult Health Maintenance Form
Advanced Care Planning

Patient Handouts

Patient FACTS

For more details about how to bill these codes, see Module 9 of Coding for Clinicians.

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Description: Learn about the annual wellness visit, the initial preventive physical examination, and the differences between them and a routine physical.

Medicare Wellness Visits

Billing for a Medicare Annual Wellness Visit: Codes G0438 and G0439

Billing for Medicare Annual Wellness Visit

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by Lucy Lamboley

The importance of using preventive medicine to improve the health and ultimately lives of patients is widely recognized. The Medicare annual wellness visit (AWV) plays an important role in helping Medicare beneficiaries stay current with their health and take actions that can prevent illness and reduce risk.

An essential piece of the process required to ensure offering and providing preventive services remains financially viable is for organizations to complete the Medicare annual wellness visit reimbursement coding process accurately. Doing so can help ensure providers receive their earned reimbursements and protect them against possible penalties they might incur from failed coding audits. We know some organizations struggle with meeting compliance requirements set forth by the Centers for Medicare & Medicaid Services.

In this blog post, we take a look at what's required for compliant AWV coding. While this is by no means a comprehensive guide to Medicare annual wellness visit reimbursement, it provides organizations with information that can assist them in avoiding some of the most common AWV coding mistakes that result in rejected claims, lost revenue, or failed audits — all of which can be mitigated when using Prevounce software.

Three Unique Annual Wellness Visit Codes: G0402, G0438, and G0439

Medicare preventive wellness visits fall into three categories; the "Welcome to Medicare" visit, also known as the Initial Preventive Physical Exam (IPPE); the initial annual wellness visit, and the subsequent annual wellness visits. Each has its own Healthcare Common Procedure Coding System (HCPCS) code that must be used in the right circumstances and proper order.

Understanding HCPCS G0402

During the first 12 months a patient is enrolled in Medicare, they are eligible for the Welcome to Medicare visit or IPPE. This is a one-time visit that includes vital measurements, a vision screening, a depression screening, and other assessments meant to gauge the health and safety of an individual patient. This visit must be coded using HCPCS G0402. Once a patient has been enrolled for more than 12 months, the G0402 code will be rejected regardless of whether the IPPE visit previously took place or not.

Understanding HCPCS G0438

After a patient has been enrolled in Medicare for 12 months, they become eligible for an annual wellness visit. Note: If you need assistance with identifying eligible patients, get this AWV quick guide .

If the Medicare beneficiary had an IPPE completed, the patient is eligible for the initial AWV on the first day of the same calendar month the following year. An AWV is similar to the IPPE but includes slightly different required and accepted screenings. This initial AWV must be coded using HCPCS G0438.

Understanding HCPCS G0439

HCPCS G0439 is used to code all subsequent Medicare annual wellness visits that occur after the initial AWV (G0438). So, if used correctly, G0439 would not be used until G0402 was used to code the IPPE and G0438 was used to code the initial AWV. In the case that an IPPE was never completed, G0439 would still be used for any subsequent visits after G0438.

Purpose of Multiple Annual Wellness Visit HCPCS Codes

Though G0402, G0438, and G0439 are commonly confused, the reason for needing three separate codes is pretty straightforward. It is assumed that the different types of visits take different amounts of resources, and so they are reimbursed at different rates.

For example, the initial annual wellness visit is used to collect the library of information that will be continually updated with each subsequent AWV. As a result, the HCPCS G0438 code is reimbursed at a rate that is nearly 50% higher than HCPCS G0439. So if an organization regularly misses using the G0438 code for an initial Medicare AWV and uses G0439 instead, it could mean numerous denials and a significant loss of revenue.

Additional AWV HCPCS and CPT Codes

In addition to the primary annual wellness visit codes (G0402, G0438, and G0439), a select list of other codes may be billed for services performed during a Welcome to Medicare visit or AWV. When using any of these codes, a separate note is required to support each rendered service.

It is important to understand that many of these codes have specific guidelines that require them only to be used with specific visits after meeting certain criteria. For example, HCPCS G0444, which designates a 15-minute annual depression screening, may only be included with subsequent wellness visits billed under G0439. If that specific code is used with the IPPE or initial AWV, it will be rejected as invalid. An abdominal aortic aneurysm (AAA) screening, coded as G0389, may only be performed with the IPPE code G0402. It is not approved for annual wellness visits.

Advance care planning (CPT 99497) is considered an optional element of the annual wellness visit, which includes a discussion with the patient about their advance care wishes and advance directive. Advance care planning, also referred to as ACP, is considered a preventive service (and thus has its co-pay waived) when billed on the same day as an AWV with modifier -33.

HCPCS G0442 and HCPCS G0443 are additional codes that must be used in conjunction with each other to be valid. G0442 is used for an annual alcohol screening, which should take approximately 15 minutes. G0443 is for 15-minute sessions of alcohol counseling. According to the Centers for Medicare & Medicaid Services (CMS), the screening service must take place before a counseling service is approved. In other words, if G0443 is used and there are no claims for G0442 in the preceding 12 months, the screening code will be denied.

Fifteen-minute obesity counseling sessions may be billed in conjunction with IPPE visits or annual wellness visits using HCPCS G0447. This service includes dietary assessments and behavioral counseling, but a patient must have a body mass index of thirty or above to qualify.

If you ever have a wellness visit that takes a particularly long time, there is also a set of add-on codes you can use. HCPCS G0513 and HCPCS G0514 are "prolonged preventive service codes" that can be used when a service takes 30 minutes (G0513) or 60-plus minutes (G0514) past the typical duration of the service.

Staying Current With Annual Wellness Visit Coding Requirements

To avoid risking an audit, it is essential to stay up to date on coding requirements associated with Medicare annual wellness visits as they undergo occasional revisions. For example, in the 2023 Physician Fee Schedule (PFS) final rule , two preventive services had their HCPCS code descriptors modified. HCPCS G0442 was changed to "Annual alcohol misuse screening, 5 to 15 minutes" and HCPCS G0444 was changed to "Annual depression screening, 5 to 15 minutes." The codes currently require a minimum of 15 minutes of services. Such coding revisions and sometimes replacement is relatively common, and utilizing incorrect codes will lead to denied claims.

With changing guidelines and eligibility requirements, the task of coding correctly to better ensure proper reimbursement on preventive health visits can prove challenging for business office staff. But without the necessary revenue, organizations may struggle to support the delivery of preventive health services, which could negatively impact the care given to patients.

Providing the Annual Wellness Visits and Preventive Care in a Financially Sustainable Way

Medicare annual wellness visits and associated preventive services are not just valuable for patients. Organizations that provide these services can increase their revenue opportunities. In fact, by expanding establishing or growing an AWV program, an organization can generate significant, recurring reimbursement, as is covered in this on-demand webinar .

But Medicare hasn't made it easy for organizations to maintain compliance with its various AWV coding, billing, documentation, and service requirements, as rules undergo regular changes that can easily be missed or misunderstood. Enter Prevounce.

Prevounce lifts the burden of sorting through Medicare regulations to help you understand how preventive services can be utilized to best benefit the patient and your organization. Our platform improves everything from AWV eligibility verification to patient outreach and intake, to billing and coding, to completion of documentation, and more. To learn what Prevounce can do for your AWV program, whether it's in its infancy or ready for significant growth, schedule a demo today !

Health economic and reimbursement information provided by Prevounce is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules, and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Prevounce encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services rendered. It is also always the provider’s responsibility to understand and comply with Medicare national coverage determinations (NCD), Medicare local coverage determinations (LCD), and any other coverage requirements established by relevant payers which can be updated frequently. Prevounce recommends that you consult with your payers, reimbursement specialists, and/or legal counsel regarding coding, coverage, and reimbursement matters. Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements. The coding options listed here are commonly used codes and are not intended to be an all- inclusive list. We recommend consulting your relevant manuals for appropriate coding options. The Health Care Provider (HCP) is solely responsible for selecting the site of service and treatment modalities appropriate for the patient based on medically appropriate needs of that patient and the independent medical judgement of the HCP.

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The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical. Also, this service is similar to but separate from the one-time Welcome to Medicare preventive visit .

Eligibility

Medicare Part B covers the Annual Wellness Visit if:

You have had Part B for over 12 months
And, you have not received an AWV in the past 12 months

Additionally, you cannot receive your AWV within the same year as your Welcome to Medicare preventive visit.

Covered services

During your first Annual Wellness Visit, your PCP will develop your personalized prevention plan. Your PCP may also:

Check your height, weight, blood pressure, and other routine measurements
This may include a questionnaire that you complete before or during the visit. The questionnaire asks about your health status, injury risks, behavioral risks, and urgent health needs.
This includes screening for hearing impairments and your risk of falling.
Your doctor must also assess your ability to perform activities of daily living (such as bathing and dressing), and your level of safety at home.
Learn about your medical and family history
Medications include prescription medications, as well as vitamins and supplements you may take
Your PCP should keep in mind your health status, screening history, and eligibility for age-appropriate, Medicare-covered preventive services
Medicare does not require that doctors use a test to screen you. Instead, doctors are asked to rely on their observations and/or on reports by you and others.
Screen for depression
Health education and preventive counseling may relate to weight loss, physical activity, smoking cessation, fall prevention, nutrition, and more.

AWVs after your first visit may be different. At subsequent AWVs, your doctor should:

Check your weight and blood pressure
Update the health risk assessment you completed
Update your medical and family history
Update your list of current medical providers and suppliers
Update your written screening schedule
Screen for cognitive issues
Provide health advice and referrals to health education and/or preventive counseling services

If you qualify, Original Medicare covers the Annual Wellness Visit at 100% of the Medicare-approved amount when you receive the service from a participating provider . This means you pay nothing (no deductible or coinsurance ). Medicare Advantage Plans are required to cover AWVs without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s eligibility requirements for the service.

During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit.

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Common questions about Medicare annual wellness visits

If you are a Medicare recipient, you can take advantage of annual wellness visits. These visits are a preventive health benefit available after having Medicare Part B coverage for at least one year. All Medicare Advantage Plans are required to offer annual wellness visits for their members. A nurse or nurse practitioner reviews your health status and helps you plan for health and wellness needs.

In most cases, the annual wellness visit will be followed by a separate medical visit with your primary care professional to close any health care gaps and address any problems identified during the visit.

Here are answers to common questions about annual wellness visits.

Why are annual wellness visits important.

The annual wellness visit allows you to review your health history and identify any current or potential health risks with a health care professional. The visit enables the nurse to focus on prevention and wellness while making sure you are current on recommended immunizations and health screenings like colonoscopies or mammograms. It also allows your primary care professional more time to focus on your medical concerns and needs at a separate physical exam.

Do I need to be 65 or older to have an annual wellness visit?

You do not need to be 65 or older to qualify for an annual wellness visit as long as you've been on Medicare Part B for at least one year.

How is an annual wellness visit scheduled?

If you are due for an annual wellness visit, you may be prompted to self-schedule the visit in the patient portal . You also may call your care team and ask to be scheduled.

If your visit is with a nurse or nurse practitioner, it's recommended to schedule this visit before the visit with your primary care professional. This allows your primary care professional the chance to address any concerns mentioned during your annual wellness visit.

How can I prepare for my annual wellness visit?

You may be asked to complete some questionnaires before arriving for your appointment, which will be sent to your patient portal account. If you cannot access the questionnaires before the appointment, plan to arrive at your appointment early to complete them.

It's helpful to come prepared to your visit with this information:

All medications, vitamins and supplements you take, including how much and how often you take them
Additional medical records, including immunization records
Dates of your most recent preventive services, like a colonoscopy or mammogram, if completed by another health care facility
Family health history, with as much detail as possible
List of medical providers and suppliers who provide you care, equipment or services

What can you expect during an annual wellness visit?

During the visit, you'll meet with a nurse or nurse practitioner to:.

Evaluate your fall risk
Measure your height, weight and blood pressure
Offer referrals to other health education or preventive services
Provide information related to voluntary advance care planning
Screen for cognitive impairments like dementia
Screen for depression
Update your medical and family history

What is the cost of an annual wellness visit?

Medicare offers the visit at no cost for people who have Medicare Part B coverage for at least one year before the visit. If you are referred for other tests or services, they will be billed to your insurance. If you have a separate visit with your primary care professional following your annual wellness visit, you or your insurance carrier will be responsible for the cost of that visit.

Robert Stroebel, M.D. , is a Community Internal Medicine, Geriatric and Palliative Care physician at Mayo Clinic Primary Care in Rochester and Kasson, Minnesota.

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Initial Preventive Physical Examination (IPPE)

As part of the Affordable Care Act, Medicare provides coverage for an IPPE for patients who have been enrolled in Medicare for less than one year. It is a one-time service, intended to help provide an introduction to insurance coverage, benefits, and give appropriate screening for disease detection and preventive promotion of health. The IPPE must be performed within the first 12 months after the effective date of the beneficiary's Medicare Part B coverage.

An IPPE includes the following seven components:

A review of the beneficiary's medical and social history
Review of the beneficiary's potential risk factors for mood disorders
Review of the beneficiary's functional ability and level of safety
An examination
End-of-life planning
Education, counseling, and referral based on the previous five components
Education, counseling, and referral for other preventive services

Annual Wellness Visit (AWV)

As part of the Affordable Care Act, Medicare provides coverage for an AWV for patients who are enrolled in Medicare. This service may be covered as often as once per year. There are two specific types of AWV: initial and subsequent. Required elements for the initial AWV include:

A self-reported health risk assessment
Establishment of the beneficiary's medical/family history
A health assessment within the office
Establishment of current providers and suppliers of service
Detection of any cognitive impairment that the beneficiary may have
Establishment of a written screening schedule for the beneficiary
Establishment of a list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended for the beneficiary
Furnishing of personalized health advice to the beneficiary, and a referral for further care, if appropriate

The subsequent AWV visit will be updating the patient's past history as established during the initial visit, as well as a new assessment to establish any needed additional treatment. This is a shorter established service. Required elements for subsequent AWVs include:

Update of the self-reported risk assessment
An update of the beneficiary's medical/family history
Update of the list of current providers and suppliers of service
Update of the written screening schedule for the beneficiary
Update of the list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended for the patient
Furnishing of personal health advice to the beneficiary, and a referral for further care, if appropriate

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Education, trainings and manuals, regulations, news and insights, annual wellness visit (awv) documentation and coding.

A Medicare Annual Wellness Visit (AWV) is not a typical physical exam. Rather, it’s an opportunity to promote quality, proactive, cost-effective care. AWVs help you engage with your patients and increase revenue.

A physician, PA, NP, certified clinical nurse specialist or a medical professional under the direct supervision of a physician (including health educators, registered dietitians and other licensed practitioners) can perform AWVs.

AWV documentation

Document all diagnoses and conditions to accurately reflect severity of illness and risk of high-cost care.

An ICD-10 Z code is the first diagnosis code to list for wellness exams to ensure that member financial responsibility is $0.

Z00.00 — encounter for general adult medical examination without abnormal findings
Z00.01 — encounter for general adult medical examination with abnormal findings

The two CPT® codes used to report AWV services are:*

G0438 — initial visit**
G0439 — subsequent visit (no lifetime limits)

Additional services (lab, X-rays, etc.) ordered during an AWV may be applied toward the patient’s

deductible and/or be subject to coinsurance. Before performing additional services, discuss them

with the patient to verify that the patient understands their financial responsibilities.

More information

For additional information and education, contact us at [email protected] .

*CPT® is a registered trademark of the American Medical Association.

**Code G0438 is for the first AWV only. The submission of G0438 for a beneficiary for which a claim code of G0438 has already been paid will result in a denial.

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Annual Wellness Visit | CPT codes

2024 CPT Codes for Annual Wellness Visits

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January 4th, 2024 | 9 min. read

2024 CPT Codes for Annual Wellness Visits

ThoroughCare

Content Team

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An Annual Wellness Visit (AWV) is a preventive screening used to identify gaps in care.

As covered by Medicare Part B, providers should understand what CPT billing codes matter to the service and how to use them. This can help your organization avoid denied claims and enhance care.

AWVs are covered for Medicare Part B patients without a co-pay. This yearly assessment helps patients create personalized care plans that providers can use to improve outcomes.

AWVs are reimbursable under Medicare’s Physician Fee Schedule, paying various rates.

AWV CPT Codes to Know: G0402, G0438, G0439

Different CPT billing codes reflect specific types of Medicare wellness visits. The crucial qualifying determinant is when a certain AWV can be provided and billed for.

2024 - AWV - CPT Codes - Chart 1 - Final

There are three types of wellness visits : Initial Preventive Physical Examination (IPPE), an Initial Annual Wellness Visit, and the Subsequent Annual Wellness Visit. Each entails a different billing code as well as specific qualifiers for each program.

Initial Preventive Physical Examination (G0402) : Patients may only receive this benefit within the first 12 months of their Medicare enrollment. Commonly referred to as the “welcome to Medicare visit,” it is considered a once in a lifetime assessment and after the initial eligibility period, the patient cannot receive an Initial Preventive Physical Examination. It is also dependent on the health risk assessment .
Initial Annual Wellness Visits (G0438) : Similar to an Initial Preventive Physical Examination, except it is available to a patient after 11 months of Medicare enrollment. This is for patients that miss their window for an Initial Preventive Physical Examination. However, if the patient does complete an Initial Preventive Physical Examination, they must still complete the Initial Annual Wellness Visit. This screening also includes an optional cognitive exam and end-of-life planning.
Subsequent Annual Wellness Visit (G0439) : Is the yearly follow-up to an Initial Annual Wellness Visit. Eleven full months after the Initial Annual Wellness Visit, a patient can attend these visits to modify and maintain their preventive care plan, based on how their health is at any given time.

About AWVs and Their Billing Requirements

Medicare’s wellness visit is a yearly assessment of a patient’s health used to identify risks and create a personalized care plan. AWVs are different from yearly physical examinations. They offer a more complete review of a patient’s medical history and current lifestyle to suggest care goals that close gaps .

Wellness visits can be of particular importance for patients living with chronic conditions.

With an AWV, a personalized care plan is designed to help manage chronic illnesses , as well as schedule preventive screenings to improve early detection of disease.

Who Can Provide AWVs?

AWV billing must be directed by a provider with an NPI number. However, clinical staff can administer most of the assessment, saving physician time and involvement. Eligible providers include:

Physician assistants
Nurse practitioners
Certified nurse midwives
Clinical nurse specialists
Pharmacists

AWV Billing Requirements

The following components must be included in a patient’s wellness visit:

A health risk assessment
A review and update of medical and family history
A review of current providers, prescriptions/medications, and durable medical equipment suppliers
Height, weight, blood pressure, BMI, and other routine measurements
Personalized health advice, health education, and preventative counseling
A list of identified risk factors, current medical and mental health conditions, and recommended treatment options
A cognitive impairment screening
A five to 10-year screening schedule for appropriate preventive services
A review of the patient’s functional ability and level of safety, including screening for hearing impairments, risk of falling, activities of daily living, and level of home safety
Identification of patients at risk for alcohol, tobacco, and opioid abuse
Advance care planning

Submitting Claims to Medicare

Five items are required when submitting a Medicare claim :

A CPT Code for the specific type of AWV provided
An ICD-10 code for a general adult medical examination (Z00.00)
Date of service
Place of service (most office in-office or telehealth)
Submit NPI number

It is helpful to know the staff care coordinator assigned to a patient in case of an audit.

Three Steps to Bill for AWVs:

Verify CMS requirements were met
Submit claims to CMS annually (or when best for your organization)
Determine there are no conflicting billing codes

Additional AWV Billing Opportunities

Medicare supports additional CPT codes for optional, add-on services related to AWVs. These include Advance Care Planning and a social determinants of health screening.

Advance Care Planning with AWVs

Advance Care Planning helps patients prepare for future medical decision-making in case of serious illness or they are unable to communicate their care preferences. Specifically, Advance Care Planning includes two primary documents:

A living will
A durable healthcare power of attorney

An AWV assessment asks patients whether they have Advance Care Planning documents in place. If not, the provider can use the AWV to discuss advance care options and schedule time to complete a plan.

CPT Code 99497

The average billing rate is $80.56. To accurately bill for code 99497, services must:

Allow for 30 minutes of a face-to-face consultation with the patient, their family member(s), and/or a surrogate (with a minimum of 16 minutes of service time documented)
Be provided by a physician or other qualified healthcare professional
Include an explanation and review of advance care directives and options for completing them

Documentation to account for at least 16 minutes of service time should record that the ACP conversation was voluntary on behalf of the patient, encapsulate what was talked about, record who was present for the conversation, and note the length of time for the consultation.

Again, it is not required to complete an advance care directive during ACP. Completion is only required if you’ve noted in your documentation that you’ve performed this task. However, when ACP is completed with an AWV, it is entirely covered for the patient .

CPT Code 99498

This is simply an add-on billing code to allow for an additional 30 minutes of ACP services. The average reimbursement rate is $69.75. Requirements for billing this code include:

Listing this billing claim separately in addition to the code for the primary consultation
That a minimum of 16 minutes past the first 30 minutes is documented using the same documentation requirements noted above.

Social Determinants of Health Assessment with AWVs

Providers can collect social determinants of health ( SDOH ) data while performing an AWV. SDOH discussions should be between 5 and 15 minutes in length, and cover food and housing insecurities, transportation needs, and utility difficulties.

The SDOH risk assessment addresses factors that influence the diagnosis and treatment of patients’ medical conditions. While not designed as a screening, the assessment is tied to one or more known or suspected SDOH needs.

CPT Code G0136

Providers can receive an additional $18.66 for assessing SDOH during an AWV. For the patient, this assessment is fully covered by Medicare when provided with an AWV.

To claim this CPT code, providers must:

Deliver 5-15 minutes of SDOH discussion
Not assess a patient more than every 6 months
Administer a standardized, evidence-based SDOH risk assessment

Medicare stresses the importance of following up with patients about SDOH and working to connect them with available resources.

AWVs for Federally Qualified Health Centers

Federally Qualified Health Centers (FQHC) can bill for AWVs, but they utilize additional codes.

In addition to the standard CPT codes associated with AWVs, an FQHC may use a special add-on code (G0468) that will support additional reimbursement.

For example, if an FQHC were to provide an Initial Preventive Physical Examination, the clinic would bill for G0402 + G0468. This coding indicates to Medicare that the service is being provided through an FQHC.

These organizations receive much higher average reimbursement rates.

AWVs Promote Value-based Care

AWVs ask about lifestyle, social history, mental health and home environment. Documenting these details can help providers risk-stratify patient populations and develop comprehensive, personalized care plans that can close gaps.

This can help clinicians better coordinate services, streamline collaborative decision-making and support value-based care delivery. AWVs have been shown to build stronger provider-patient relationships, secure additional revenue and contribute to cost savings.

ThoroughCare Simplifies Annual Wellness Visits

ThoroughCare offers end-to-end workflow for Annual Wellness Visits.

We simplify the process, so providers can focus on engaging patients. Guided interviews help ask the right questions and ensure all service requirements are met. ThoroughCare includes digital solutions, such as:

An interactive health risk assessment
Screening tools, such as ADL, CAGE, DAST-10, GAD-7, MDQ, PAC, PHQ-2, and a mini cognitive exam
A care gaps summary with recommended interventions
A full report of Personalized Prevention Plan Services
Comprehensive care planning tools
Automated CPT code assignment for accurate billing

*Reimbursement rates are based on a national average and may vary depending on your location.

Check the Physician Fee Schedule for the latest information.

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U.S. Dept. of Health & Human Services

A Social Determinants of Health Risk Assessment in the Annual Wellness Visit Policy Update in the Calendar Year 2024 Physician Fee Schedule Final Rule

The purpose of this Change Request (CR) is to make contractors aware of policy updates for a Social Determinants of Health (SDOH) Risk Assessment in the Annual Wellness Visit (AWV) resulting from changes specified in the Calendar Year (CY) 2024 Physician Fee Schedule (PFS) Final Rule (88 FR 78818), published in the Federal Register on 11/16/2023.

Download the Guidance Document

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: May 02, 2024

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

Providing Medicare wellness visits can be challenging but can improve quality and practice revenue.

ARNOLD E. CUENCA, DO, CAQSM, FAAFP, AND SUSAN KAPSNER, CCS

Fam Pract Manag. 2019;26(2):25-30

Author disclosures: no relevant financial affiliations disclosed.

Editor's note: This is a corrected version of the article previously published.

The Affordable Care Act of 2010 created the Medicare annual wellness visit (AWV) as a way to provide patients with comprehensive preventive care services at no cost. Yet many practices have been slow to provide substantial numbers of these visits. Only 15.6 percent of eligible patients received an AWV through 2014. 1 In addition to finding lackluster overall participation, researchers have found AWV rates are lower among practices caring for underserved populations, such as racial minorities, rural residents, or those dually enrolled in Medicaid. 2

Physicians and other health care providers do not offer AWVs to their Medicare patients for numerous reasons. Providing and documenting all of the required AWV elements efficiently can be challenging, and some practices may feel their staffing or electronic health record resources are too limited. Many patients and even some physicians may not know what the AWV entails, and patients with complex socioeconomic risk factors may have pressing health conditions that need to take priority over preventive services. These explanations can all be valid, but this article seeks to help physicians reevaluate the AWV, along with the initial preventive physical examination (IPPE) or “Welcome to Medicare” visit, and recognize the value these wellness visits can bring not only to their patients but also to their practices or health care organizations.

The Medicare annual wellness visit (AWV) and the initial preventive physical examination (IPPE) provide a number of benefits to patients and physicians, but many physicians still do not provide them.

Medicare wellness visits can help physicians address care gaps and report quality measures important in pay-for-performance systems.

When billed correctly and delivered efficiently along with other covered Medicare preventive services, AWVs can boost practice revenue.

THE VALUE OF MEDICARE WELLNESS VISITS

The main benefit of the AWV to patients is the creation of a personalized prevention plan, a written plan that can help guide their preventive care decisions for the next five to 10 years. This plan includes age-appropriate preventive services, recommendations offered by both the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices, and personalized health advice that identifies risk factors and suggests referrals or programs to address them. 3

Providing Medicare wellness visits also offers a structure that helps physicians to close many pay-for-performance quality measure gaps, including those recognized by the Core Quality Measures Collaborative, the Integrated Healthcare Association’s California Value Based P4P program, and the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set. In addition, accountable care organizations participating in the Medicare Shared Savings Program can use data collected during wellness visits to satisfy specific quality measures for the 2018 and 2019 quality reporting years. 4 (See “ Closing quality measure gaps .”)

There also are financial incentives to implementing AWVs. Physicians participating in Medicare’s Merit-based Incentive Payment System (MIPS) can use AWVs to raise their quality scores, which can potentially lead to positive Medicare payment adjustments. Practices that provide AWVs often generate greater revenue than those that do not – a result of billing AWVs with associated preventive services and same-day problem-oriented services. 2 AWVs also provide physicians another opportunity to assess and report risk-adjusted diagnoses for Medicare Advantage beneficiaries. Future payment rates for higher risk patients are calculated based on risk-adjusted factor (RAF) scores, so addressing Hierarchical Condition Category-related diagnoses in the same visit can be of additional value. (For more on this subject, see “ Is Your Diagnosis Coding Ready for Risk Adjustment? ” FPM , March/April 2018, and “ Diagnosis Coding for Value-Based Payment: A Quick Reference Tool ,” FPM , March/April 2018.)

CLOSING QUALITY MEASURE GAPS

Many pay-for-performance measures can be addressed during Medicare wellness visits, including these, which are associated with the following programs: Core Quality Measures Collaborative (Collaborative), the Integrated Healthcare Association’s California Value Based P4P Program (IHA), and the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS). Measures used by the Medicare Shared Savings Program (MSSP) 2018 and 2019 reporting years are also listed.

HOW TO CODE FOR MEDICARE WELLNESS VISITS

The type of wellness visit you report depends on when the patient joined Medicare.

The IPPE is a one-time physical exam performed within the first 12 months of a patient’s enrollment under Part B Medicare. The initial AWV can be provided 12 months after the patient first enrolled or 12 months after he or she received the IPPE. A subsequent AWV can then be provided annually.

Physicians should bill for preventive services provided in addition to the AWV or IPPE, many of which carry work relative value units (wRVUs) that can affect their productivity scores and revenue. Some of these services are payable by Medicare in addition to the AWV or IPPE and can be performed several times during the year. However, patients and physicians should be aware that a few of these services do have a copay or deductible. (See “ Medicare-covered preventive services .”)

MEDICARE-COVERED PREVENTIVE SERVICES

This table includes preventive services that generate work relative value units (wRVUs). For a complete list of Medicare preventive services, see https://go.cms.gov/2sK65XA .

If you provide advance care planning (ACP), CPT code 99497 or 99498, at the same visit, make sure to append modifier 33, “Preventive service,” so that the usual coinsurance and deductible charged for the ACP is waived. 5 You may need to append modifiers to other preventive service codes as well, to avoid bundling. Practices should check with their Medicare contractor for guidance.

To find out how many wRVUs a particular service is worth, see the 2019 Medicare Physician Fee Schedule ) or the wRVU calculator provided by the American Academy of Professional Coders.

Below are some examples of wellness visits and the wRVUs resulting from each one.

Patient 1 : A 67-year-old male, who is an established patient of your practice, is seeing you for an initial AWV. His chronic problems include hypertension and dyslipidemia. He is taking hydrochlorothiazide 25 mg per day and atorvastatin 20 mg at bedtime. His history and the health risk assessment he completed confirm he has smoked one pack of cigarettes per day for 34 years. He does not have an advance directive. He rarely drinks alcohol, and his PHQ-2 depression screening score is zero. His vital signs are stable with good blood pressure control. His BMI is 33.7. He requests a digital rectal exam (DRE) because his father had prostate cancer. You create the patient’s personalized prevention plan and discuss your clinical recommendations with the patient, who agrees to receive several preventive services, including a lipid panel, diabetes screening, hepatitis C screening, lung cancer screening with a low-dose CT scan, a pneumococcal vaccination, a DRE, and AAA screening with ultrasound. You order the labs and imaging, provide counseling focused on several of the patient’s health risk behaviors, and recommend a follow-up visit in six months or sooner if needed to address test results.

Patient 2 : A 77-year-old female, who is an established patient of your practice, is seeing you for her first AWV. She has a Medicare Advantage insurance plan. Her previous office visit was about nine months ago. She has diabetes, hypertension, peripheral neuropathy, glaucoma, mild major depression, anxiety, and COPD. She is due for her routine lab work and is requesting refills of all her medications. She would like a flu shot, but the rest of her immunizations are current. Her list of medications includes metformin 500 mg twice a day, sitagliptin 50 mg daily, lisinopril 10 mg daily, gabapentin 300 mg three times per day, albuterol as needed, tiotropium daily, alprazolam 0.25 mg daily as needed, sertraline 50 mg daily, and dorzolamide ophthalmic twice a day. She has tried in the past to wean herself off the alprazolam but needs it to control her anxiety; she fills her prescription for 30 pills every three or four months, which you confirm via a controlled substance prescription database. Her history, along with her health risk assessment, shows she drinks up to three glasses of wine per day. She does not have an advance directive. Her vital signs are stable with good blood pressure control, and her BMI is 22.4. You address her concerns and order labs appropriate to her chronic medical conditions, refill her medications, order a flu shot, provide counseling related to her health risk behaviors, and discuss your preventive service recommendations as part of her personalized prevention plan, which includes ordering a DEXA scan.

Given the complexity of her health status, you ask her to schedule a follow-up appointment in one week to go over her lab results. Also, because the patient is a Medicare Advantage beneficiary, you remember to assess and report risk-adjusted diagnoses and HCC codes.

Patient 3 : A 57-year-old female, who is an established patient of your practice, recently became disabled. She now has dual insurance coverage with Medicare and Medicaid. She is scheduled for her “Welcome to Medicare” visit. She was seeing a partner of yours who recently retired, and she has transferred to you for care. Her last visit was four weeks ago, and her diabetes lab work at that time showed that her A1C was 6.7 and her LDL was 94. She had her annual eye exam two months ago. She has diabetes, hypertension, and end-stage renal disease (ESRD). Her list of medications includes insulin glargine 10 units at bedtime, insulin aspart on a sliding scale, amlodipine 5 mg daily, and pravastatin 10 mg at bedtime. Her history, along with her health risk assessment, shows that she has multiple sex partners. She does not drink alcohol and does not smoke. Her PHQ-2 depression screening is 0. Her last mammogram was three years ago, and her last Pap smear was six years ago. She has not received her pneumococcal vaccine. She has never had a colonoscopy or fecal occult blood testing. Her vital signs are stable with good blood pressure control and a BMI of 27.1. She has been feeling sick for the last two weeks with sinus infection symptoms. You treat her for a sinus infection, perform a gynecologic exam and Pap smear, and update her pneumococcal vaccination. You discuss and then order screens for hepatitis B, hepatitis C, HIV, and sexually transmitted infections (STIs), in addition to a mammogram. You also agree to make referrals for a colonoscopy and medical nutrition therapy for ESRD. Finally, you ask her to follow up in four to six months or as needed.

MEETING THE CHALLENGE

Providing wellness visits is not easy, but there are ways to make your practice more prepared. For example, a nurse or medical assistant could handle pre-visit planning to make the physician-led visit more efficient. 6 Another variation of the team-based model, which used a dedicated scheduler to contact Medicare patients about AWVs and then clinical pharmacists and licensed practical nurses to provide the visits, significantly increased use of preventive services. 7 It may also be worthwhile to set aside more time for these types of visits. While some visits can be completed in 30 to 40 minutes, more complicated encounters may take longer. Your EHR may also have templates and other tools available to make providing Medicare wellness visits more efficient, although the range of EHR capabilities is too wide to discuss here.

Regardless of how you schedule and perform these visits, you should recognize that Medicare wellness visits have great value in not only providing important preventive services to the patient but also closing quality measure gaps and contributing financial stability to a practice or organization.

Ganguli I, Souza J, McWilliams JM, Mehrotra A. Trends in use of the U.S. Medicare annual wellness visit, 2011–2014. JAMA . 2017;317(21):2233-2235.

Ganguli I, Souza J, McWilliams JM, Mehrotra A. Practices caring for the underserved are less likely to adopt Medicare’s annual wellness visit. Health Aff (Millwood) . 2018;37(2):283-291.

CMS. Annual wellness visit, including personalized prevention plan services. MLN Matters . March 2, 2016. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7079.pdf . Accessed Jan. 30, 2019.

CMS. Medicare Shared Savings Program: Quality Measure Benchmarks for the 2018 and 2019 Reporting Years, Guidance Document . December 2017. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2018-and-2019-quality-benchmarks-guidance.pdf . Accessed Jan. 30, 2019.

CMS. Advance care planning. MLN Matters fact sheet. June 2018. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf . Accessed Jan. 30, 2019.

Cuenca AE. Making Medicare annual wellness visits work in practice. Fam Pract Manag . 2012;19(5):11-16.

Galvin SL, Grandy R, Woodall T, Parlier AB, Thach S, Landis SE. Improved utilization of preventive services among patients following team-based annual wellness visits. NC Med J . 2017;78(5):287-295.

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