Understanding the Medicare Annual Wellness Benefit
Medicare Annual Wellness Visit
Medicare covers an Annual Wellness Visit (AWV) providing Personalized Prevention Plan Services (PPPS) for beneficiaries who: Are not within the first 12 months of their first Medicare Part B coverage period; and Have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months.
Medicare covers an AWV for all beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period and who have not gotten either an IPPE or an AWV within the past 12 months (that is, at least 11 months have passed following the month in which the IPPE or the last AWV was performed). Medicare pays for only one first AWV per beneficiary per lifetime and pays for one subsequent AWV per year thereafter.
Coding, Diagnosis, and Billing
Coding
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
Diagnosis
Since CMS does not require a specific diagnosis code for the AWV, you may choose any appropriate diagnosis code. You must report a diagnosis code.
Billing
Medicare Part B covers AWV if performed by a: Physician (a doctor of medicine or osteopathy); Qualified non-physician practitioner (a physician assistant, nurse
practitioner, or certified clinical nurse specialist); or Medical professional (including a health educator, registered dietitianutrition professional, or other licensed practitioner) or a team of such medical professionals who are working under the direct supervision of a physician (doctor of medicine or osteopathy).
When you provide a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service in addition to the AWV, Medicare may pay for the additional service. Report the Current Procedural Terminology (CPT) code with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury or to improve the functioning of a malformed body member.
Frequently Asked Questions (FAQs) about the AWV.
Question: Is the AWV the same as a beneficiary’s yearly physical?
Answer: No. The AWV is not a “routine physical checkup” that some seniors may
get every year or so from their physician or other qualified non-physician
practitioner. Medicare does not cover routine physical examinations.
Question: Are clinical laboratory tests part of the AWV?
Answer:No. The AWV does not include any clinical laboratory tests, but you may make
referrals for such tests as part of the AWV, if appropriate.
Question: Do deductible or coinsurance/co-payment apply for the AWV?
Answer: No. Medicare waives both the coinsurance or co-payment and the Medicare
Part B deductible for the AWV.
Question: Can I bill an electrocardiogram (EKG) and the AWV on the same date
of service?
Answer:Generally, you may provide other medically necessary services on the same
date of service as an AWV. The deductible and coinsurance/co-payment apply
for these other medically necessary services.
The Annual Wellness Visit is a great program for primary care physicians to provide to their Medicare patients. MedSource provides a turnkey solution that takes the challenges of administering the Medicare patient benefit out of the practice and allows both the patient to receive better care and improves the performance of the practice. Contact MedSource today ( [email protected] ) to learn more about our turnkey Medicare Annual Wellness Visit solution.
Original CMS Documentation for the AWV is provided below. Please note to check the CMS website for updates to this program.