annual wellness visit medicare cpt

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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.

Yearly "Wellness" visits

If you’ve had Medicare Part B (Medical Insurance) for longer than 12 months, you can get a yearly “Wellness” visit to develop or update your personalized plan to help prevent disease or disability, based on your current health and risk factors. The yearly “Wellness” visit isn’t a physical exam.

Your first yearly “Wellness” visit can’t take place within 12 months of your Part B enrollment or your “Welcome to Medicare” preventive visit. However, you don’t need to have had a “Welcome to Medicare” preventive visit to qualify for a yearly “Wellness” visit.

Your costs in Original Medicare

You pay nothing for this visit if your doctor or other health care provider accepts assignment .

The Part B deductible  doesn’t apply. 

However, you may have to pay coinsurance , and the Part B deductible may apply if your doctor or other health care provider performs additional tests or services during the same visit that Medicare doesn't cover under this preventive benefit.

If Medicare doesn't cover the additional tests or services (like a routine physical exam), you may have to pay the full amount.

Your health care provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your doctor develop or update a personalized prevention plan to help you stay healthy and get the most out of your visit. Your visit may include:

• Routine measurements (like height, weight, and blood pressure).
• A review of your medical and family history.
• A review of your current prescriptions.
• Personalized health advice.
• Advance care planning .
• A screening schedule (like a checklist) for appropriate preventive services.
• An optional “ Social Determinants of Health Risk Assessment ” to help your provider understand your social needs and their impact on your treatment.  

Your health care provider will also perform a cognitive assessment to look for signs of dementia, including Alzheimer’s disease. Signs of cognitive impairment include trouble remembering, learning new things, concentrating, managing finances, and making decisions about your everyday life. If your health care provider thinks you may have cognitive impairment, Medicare covers a separate visit to do a more thorough review of your cognitive function and check for conditions like dementia, depression, anxiety, or delirium and design a care plan.

If you have a current prescription for opioids, your doctor or other health care provider will review your potential risk factors for opioid use disorder, evaluate your severity of pain and current treatment plan, provide information on non-opioid treatment options, and may refer you to a specialist, if appropriate. Your doctor or other health care provider will also review your potential risk factors for substance use disorder, like alcohol and tobacco use , and refer you for treatment, if needed. 

Related resources

• Preventive visits
• Social determinants of health risk assessment

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March 1, 2023

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

by Lucy Lamboley

• Medicare Annual Wellness Visit

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 ! 

CPT Copyright 2023 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

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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Annual Wellness Visit

What Are the 2022 CPT Codes for Annual Wellness Visits?

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January 12th, 2022 | 6 min. read

ThoroughCare

Content Team

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Medical reimbursements are tied to Current Procedural Terminology (CPT) codes. They categorize and specify billing rates and rules for procedures, treatments, and care services. 

If you’re a medical care provider, you likely know this. But do you know the rates and workflows for Medicare’s wellness programs? Like, Annual Wellness Visits (AWV) )? 

Knowing the billing codes for AWVs will give you a better idea of what’s expected, both by the patient and Medicare. 

Understanding billing codes will also help you project revenues and optimize your staff’s capacity . Without this information, you risk disorganization and a clouded outlook. 

At ThoroughCare, we’ve worked with clinics and physician practices across the US  to help them streamline and capture Medicare reimbursements.  Our software solution assists with rules and regulations for AWVs, and it tracks all activities related to providing the program, such as conducting patient assessments, making it easier to bill for. 

In this article, we’ll briefly review the requirements of AWVs, as well as the program’s CPT codes. 

How Do Annual Wellness Visits Work?

As the name suggests, an AWV is a yearly assessment of one’s current health. It is entirely FREE for anyone covered by Medicare Part B. 

A doctor uses the time to discuss health history, identify potential issues and answer an individual’s questions. The overall goal is to establish a record of a person’s physical and mental well-being for the purpose of preventive health planning. 

An AWV should not be confused with a routine physical examination . The AWV is more about recognizing possible gaps in a patient’s healthcare and planning the next steps. It should include:

A review of your medical and family history.

Developing or updating a list of current providers and prescriptions.

Height, weight, blood pressure, and other routine measurements.

Detection of cognitive impairment.

Personalized health advice.

A screening schedule (or checklist) for appropriate preventive services. 

By participating, a patient will receive a personalized risk prevention plan, targeted for specific diseases or disabilities relevant to their situation. 

Wellness visits come in three varieties . 

There is the Initial Preventive Physical Examination (IPPE), an Initial Annual Wellness Visit (IAWV), and the Subsequent Annual Wellness Visit (SAWV). All are fairly similar, yet it’s important to understand the differences as it relates to billing . We’ll cover this more below.

How to Bill for Annual Wellness Visits

There are five items required when submitting a claim through CMS :

• A CPT Code for the specific type of AWV provided
• A ICD-10 code for a general adult medical examination
• Date of service
• Place of service
• Provider name

While it’s not needed, it is helpful to know the care manager assigned to a patient in case you’re ever audited: When billing, you’ll calculate the time spent with each of your patients monthly.

These are the four steps you’ll take when billing:

• Verify CMS requirements were met
• Submit claims to CMS monthly
• Send an invoice to patients receiving an annual visit
• Make sure there are no conflicting codes that have been billed

CPT Codes for Annual Wellness Visits

For 2023 reimbursement information, click here . Below, we break down the four types of billing codes for AWVs, as well as advanced care planning.

For an IPPE, your patients may only receive this benefit within the first 12 months of their Medicare enrollment . It is considered a “once in a lifetime” assessment. After the initial eligibility period, your patient cannot receive an IPPE. It is also dependent on a health risk assessment (HRA) . 

An IAWV is practically identical to an IPPE, except it is available to your patient after 11 months of Medicare enrollment . It is for patients that miss their window for an IPPE. However, if your patient does complete an IPPE, they must still complete the IAWV. An HRA drives the IAWV process, as well. But this screening also includes an optional cognitive exam and “end-of-life” planning. 

The Subsequent AWV is the yearly follow-up to an IAWV . Eleven months after an IAWV, a patient can attend these sessions to modify and maintain their preventive care plan, based on how their health is at any given time. 

As the years pass, and the patient’s health evolves, the doctor may use the Subsequent AWV to guide individuals toward other Medicare preventive programs, such as Chronic Care Management (CCM) , Behavioral Health Integration (BHI) , or Remote Patient Monitoring (RPM) . 

AWV for Federally Qualified Health Clinics and Advanced Care Planning

As shown above, CPT code G0468 allows federally qualified health clinics (FQHC) to bill for AWVs. This code covers all three varieties of AWVs at the same reimbursement rate. 

That said, you would still provide the type of AWV most appropriate based on your patient’s eligibility window. 

Advanced care planning (ACP) is not a type of AWV , but it can play a part in the program. 

ACP is a formal process to understand your patient’s preferences for future medical care. It is an opportunity to make a plan. And an AWV can be a chance to create it. Often, providers will complete ACP during an AWV. 

ACP is fully covered for patients under Medicare Part B , so long as it is conducted during the AWV. And it is reimbursable for your practice. It can be billed in concurrence with an AWV using CPT code 99497. 

Streamline AWVs With Care Coordination Software

Knowing  the CPT codes for AWVs  can help your practice project revenue and optimize your care team’s capacity. But t o deliver and document wellness visits, you’ll want a system in place to manage your program.

A practical resource, such as care coordination software , will keep key details from being lost or overlooked. This will promote efficiency for you and your staff and help patients succeed. Care coordination software can streamline the creation of patient care plans, support staff workflows, and simplify billing. ThoroughCare’s software solution offers these exact features. 

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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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• Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.
• While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government.
• Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.
• Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.
• Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.

Medical clinical policy bulletins

• Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider.
• While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
• Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error.
• CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.
• Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern.
• In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. 

See CMS's Medicare Coverage Center

• Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change.
• Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. Under certain circumstances, your physician may request a peer to peer review if they have a question or wish to discuss a medical necessity precertification determination made by our medical director in accordance with Aetna’s Clinical Policy Bulletin.
• While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans.

See Aetna's External Review Program

• The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT®), copyright 2015 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
• The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT®")

CPT only copyright 2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association.

You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.

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Advance Health Equity

Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health :

• Health Equity Technical Assistance Program
• Disparities Impact Statement

Telehealth Eligible Services

• List of Telehealth Services
• Telehealth Services
• Billing for telehealth

The COVID-19 public health emergency (PHE) ended at the end of the day on May 11, 2023. View Infectious diseases for a list of waivers and flexibilities that were in place during the PHE.

How do I determine the last date a patient got a preventive service so I know if they’re eligible to get the next service and it won’t deny due to frequency edits?

Learn how to check eligibility . You may access eligibility information through the CMS HIPAA Eligibility Transaction System (HETS) either directly or through your:

• Eligibility services vendor
• Medicare Administrative Contractor (MAC) provider call center interactive voice response (IVR) unit
• MAC provider web portal

Contact your eligibility service vendor or find your MAC’s website .

My patients don’t follow up on routine preventive care. How can I help them remember when they’re due for their next preventive service?

We offer a Preventive Services Checklist so they can track their preventive services.

When can CMS add new Medicare preventive services?

We may add preventive services coverage through the National Coverage Determination (NCD) process if the service is:

• Reasonable and necessary for prevention or early detection of illness or disability
• U.S. Preventive Services Task Force (USPSTF)-recommended with grade A or B
• Appropriate for people entitled to Part A benefits or enrolled under Medicare Part B

We may also add preventive services through statutory and regulatory authority.

USPSTF Published Recommendations has more preventive services information.

What’s a primary care setting?

We define a primary care setting as a place where clinicians deliver integrated, accessible health care services and are responsible for addressing most patient health care needs, developing a sustained patient partnership, and practicing in the context of family and community. Under this direction, we don’t consider emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices as primary care settings.

• CMS Preventive Services
• National Training Program Resources

Disclaimers

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Our previous issue described the requirements and introduced an encounter form for documenting these visits. Now we answer your questions about this newest Medicare benefit.

CINDY HUGHES, CPC

Fam Pract Manag. 2011;18(2):13-15

Cindy Hughes is the AAFP's coding and compliance specialist, a contributing editor to Family Practice Management and co-author of FPM 's Getting Paid blog at http://blogs.aafp.org/fpm/gettingpaid/ . Author disclosure: nothing to disclose.

The expansion of Medicare preventive services coverage that took effect on Jan. 1 of this year provides a valuable opportunity for you and your patients to focus on preventive screening and wellness, particularly in the context of an annual wellness visit (AWV), the newest Medicare benefit. However, providing and billing for such visits is, of course, complicated. Our January/February issue cover story provided an overview of Medicare preventive services and two tools to help you deliver, document and bill for them, but a single article could not cover all the details associated with these benefits. You responded with a number of good questions, the answers to which are given below.

What ICD-9 codes should be used with the HCPCS codes for annual wellness visits (G0438 and G0439)?

The Centers for Medicare & Medicaid Services (CMS) did not specify the ICD-9 codes that should be used. Individual Part-B contractors may designate specific codes, but typically ICD-9 codes in the V70 range have been accepted.

Do I understand correctly that, other than measuring vital signs, no physical exam is required?

The following vitals – height, weight, BMI or waist circumference, blood pressure and other measurements as appropriate – are the minimum requirements. Physicians must determine the level of physical examination necessary to create a personalized prevention plan based on the patient's risk factors and health goals and to encourage patient utilization of other preventive services, as this is the purpose of the AWV. Remember that you may provide other covered Medicare preventive services at the same encounter if indicated and your schedule permits, although you should check with the Medicare administrative contractor in your region to confirm that you will be paid for the additional service, as described in the next question.

If I perform the clinical breast and pelvic exam (G0101) at the same encounter as the AWV, will Medicare pay for the breast and pelvic exam in addition to the AWV?

CMS has yet to address this issue. It would be best to direct this question to your Medicare administrative contractor. For example, WPS, the contractor for Kansas, Missouri, Nebraska and Iowa, says, “Medicare can allow both services. However, you must carve out of your pricing for the AWV any services that may be duplicated in the screening breast or pelvic exam.”

In other words, because WPS considers the breast and pelvic exam to overlap with the exam portion of the AWV, physicians must subtract the amount charged for the breast and pelvic exam from their usual charge for the AWV. The Pap smear collection and handling (Q0091) could probably be charged without a reduction of the AWV fee.

Does documenting that a patient was “alert and oriented × 3” (to person, place and time) cover the requirement to “review and document the detection of any cognitive impairment that the individual may have”?

No. CMS defines the assessment as follows: “Detection of any cognitive impairment, for purposes of this section, means assessment of an individual's cognitive function by direct observation, with due consideration of information obtained by way of patient report, concerns raised by family members, friends, caretakers, or others.”

Therefore, your documentation should include an assessment gained from observation, patient interview and input from caregivers present at the encounter. CMS does not require that physicians use a specific assessment tool, but the documentation should include evidence of assessment, such as notations of the patient's general appearance, affect, speech, memory and motor skills.

Does the initial annual wellness visit (HCPCS code G0438) apply only to patients who are new to my practice?

No. The AWV codes do not distinguish between new and established patients. Rather, the initial AWV is billed the first time a Medicare beneficiary receives an AWV that includes all of the elements required by CMS. The subsequent AWV code is reported for patients who have previously received an AWV service, whether at your practice or elsewhere.

It will be difficult to be certain whether one year has elapsed since the Welcome to Medicare visit or initial AWV if the patient is new to my practice. Is it necessary to provide patients with an Advance Beneficiary Notice (ABN) so that we can bill them should they receive the subsequent service prior to their eligibility?

No ABN is required, but it is a good idea to verify the patient's preventive services eligibility and provide those who request the service prior to eligibility with an ABN confirming their agreement to pay. Based on CMS instructions to Medicare contractors, claims for an AWV provided before 11 full months have passed since the last AWV will be denied with a “PR” code, indicating patient responsibility. Note that knowledge of the patient's past preventive services, such as last colonoscopy or the onetime benefit for the pneumococcal vaccination, will facilitate development of the preventive care plan at the annual wellness visits. If your practice is not using the 270/271 electronic eligibility transactions or another Medicare eligibility inquiry program, you may wish to consider options for incorporating this into your scheduling or pre-visit preparation processes.

Where can we learn about conducting electronic eligibility inquiries to determine our patient's eligibility for Medicare preventive services?

You may contact your Medicare administrative contractor, your practice management software vendor or your claims clearinghouse for specific information on options available to you. These will likely include the 270/271 electronic inquiries that are conducted like electronic claims submissions, with the 270 sending your inquiries and the 271 returning the report to you. Another option may be to use the online provider-service portal offered by the Medicare administrative contractor; this may be less expensive and meet your needs if you don't expect to make daily inquiries. However, the 270/271 transactions likely allow for batch inquiries that could save time and effort when inquiries for multiple patients are necessary. These resources can also help determine which patients have Medicare Advantage coverage or have Medicare as a secondary payer.

What is the definition of a “health professional” or “health educator,” both of which may provide AWVs if working under the supervision of a physician, according to the regulations? Do these individuals need to have received formal education leading to a specific degree, or can they be trained?

Neither the legislation that expanded the preventive services benefits (the Affordable Care Act) nor the regulations that CMS created and implemented provide an answer to this question. Given that, the criteria may boil down to whether the person is licensed in the state, working within the scope of practice allowed by the state and, as you said, under the direct supervision of a physician. The concept of team care should enable physicians to include the licensed professionals who are best suited to provide a portion of the AWV service, based on individual patients' needs. Remember that “direct supervision” requires the physician to be in the office suite and readily available to offer assistance and direction as needed. The AWV should be billed by the supervising physician.

Note that the regulations allow physician assistants, nurse practitioners and clinical nurse specialists to provide the AWV. Physician supervision of these health care providers should align with state requirements. For instance, where direct supervision of nurse practitioners is not required, the nurse practitioner may provide and bill for the AWV under his or her NPI number.

Can I still provide a preventive service as described by CPT codes 99387 and 99397 to Medicare patients who wish to have a routine physical that doesn't include all the elements of an AWV?

Yes. The CPT preventive service codes could be submitted when the elements required for an AWV are not provided but the service meets CPT's definition of an age- and gender-appropriate preventive medicine service. These services are still not covered by Medicare Part B and as such are an out-of-pocket expense to the patient. If you provide a Medicare-covered service (such as a breast or pelvic exam) on the same date, you must subtract the Medicare payment for the covered service from your usual charge for the preventive service before billing the patient.

If a patient requests a head-to-toe physical and the AWV, may I bill for both?

CMS stated in the final rule for the 2011 Medicare Physician Fee Schedule that both services may be billed but also noted that “it would be difficult to distinguish an AWV from another preventive medicine E/M service furnished in the same encounter that would be reported under a preventive medicine services E/M CPT code as there is substantial overlap in the components of CPT codes 99381 through 99397 and HCPCS codes G0438 and G0439 reported for the AWV.” If you choose to provide and bill for both services on the same date, you should take into account the overlap of elements such as history and counseling when determining what to charge the patient for the non-covered preventive service (99381–99397).

How does payment for the AWV compare to payment for a preventive service described by CPT codes 99387 or 99397?

Since there is no Medicare coverage for the preventive services visits described by CPT, these codes are not priced in the Medicare Physician Fee Schedule. However, CMS does assign relative value units (RVUs) to them. The RVUs for the initial annual wellness visit are higher than the RVUs for either of the preventive services visits, and the RVUs for the subsequent annual wellness visit are lower than these. Here are the total RVUs assigned to each of the relevant services: G0438 – 4.74, G0439 – 3.16, 99387 – 4.16, and 99397 – 3.48. In general, the higher the RVUs, the higher the payment.

We hope these answers will make it a bit easier to provide your patients with the preventive services they need.

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