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Welcome to Medicare Visit (IPPE) &
Annual Wellness Visit (AWV) Revenue.

Annual Wellness Visit & Welcome to Medicare Visit / Initial Preventive Physical Examination

Annual Wellness Visit &

Welcome to Medicare Visit / Initial Preventive Physical Examination

Overview

An ounce of prevention is worth a pound of cure!

CMS has recognized the need to promote more preventative measures in the healthcare setting and the need to make healthcare more patient-centric, which is why in 2010 Medicare introduced the Welcome to Medicare Initial Preventive Physical Examination IPPE and the Annual Wellness Visit as added benefits provided to its beneficiaries that are designed to help Medicare beneficiaries and their doctors develop personalized prevention plans, at no cost to the patient, that take a comprehensive approach to improving health and preventing disease.

The Annual Wellness Visit is similar to the one-time Welcome to Medicare preventive visit but has important added benefits and is a continuous yearly benefit. Both IPPE and AWV visits are designed to help Medicare beneficiaries and their doctors develop personalized prevention plans, at no cost to the patient, that take a comprehensive approach to improving health and preventing disease. However, it is important to note the timing of these added benefits, the Welcome to Medicare IPPE needs to take place within the first year the beneficiary is enrolled in Medicare, the AWV would take place in the subsequent years.

Annual Wellness Visit ROI and IPPE ROI is substantial for practices and healthcare organizations. However, because of time constraints on the clinicians less than 20% of physicians are providing annual wellness visits to their patients.

CareVitality, Inc. has created a comprehensive service offering to alleviate the burden these visit types can place on the practice as well as a complete annual wellness visit implementation guide to help practices and healthcare organizations implement this valuable service to their Medicare patient populations.

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Benefits of the Welcome to Medicare Visit/ Initial Preventive Examination & Annual Wellness Visit

Medicare covers a yearly appointment to discuss your plan of preventive care in the coming year.

This appointment is either the Initial Preventive Examination or the Annual Wellness Visit. The Annual Wellness Visit is similar to the one-time Welcome to Medicare Visit IPPE but has important differences. For example, like the Welcome to Medicare visit, the Annual Wellness Visit is not a head-to-toe physical. However, a Medicare patient cannot receive their Annual Wellness Visit within the first year they are enrolled in Medicare or within the same year the patient has their Welcome to Medicare exam.

The welcome to Medicare Visit IPPE and the Annual Wellness Visit AWV provide a preventive examination of the patient and counseling, referrals for other preventives as well as reduce identified risk factors and promote wellness to include:

  • weight loss
  • physical activity
  • smoking cessation
  • fall prevention
  • nutrition

Original Medicare covers the Annual Wellness Visit with no coinsurance or deductible. Medicare Advantage Plans cover all preventive services the same as Original Medicare. This means Medicare Advantage Plans will not be allowed to charge cost-sharing fees (coinsurances, copays or deductibles) for preventive services that Original Medicare does not charge for as long as the patient sees in-network providers. If the patient sees providers that are not in your plan’s network, charges will typically apply.

Note: If the patient receives any additional services or screenings during the welcome to Medicare, Initial Preventive Physical Exam or Annual Wellness Visit, then the patient may have an additional charge for those services. Services not included in the IPPE or AWV will be billed separately. The patient may be charged your usual copay and deductible if the additional service is covered by Medicare.

If the patient receives any additional services not covered under Medicare, such as a routine hearing exam, then the patient or their supplemental insurance will be responsible for 100 percent of its cost.

If the provider furnishes a significant, separately identifiable medically necessary Evaluation and Management (E/M) service in addition to the IPPE, 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.

How CareVitality Can Help

At CareVitality we provide a turnkey Welcome to Medicare, Initial Preventive Physical Examination (IPPE) & Annual Wellness Visit (AWV) service offering that will alleviate almost all the administrative burden of implementing a IPPE & AWV Program.

We created this offering due to the extensive requirements of the IPPE & AWV, physicians have been slow to submit claims. For the third year of the new codes, only 12% of eligible beneficiaries had Medicare billings for these services, according to 2013 data from the Centers for Medicare and Medicaid Services.

Since Welcome to Medicare (IPPE) and Annual Wellness Visits provide a lot of benefits to patients and give providers a roadmap to providing valuable and preventative care to their Medicare patients, as well as financial incentive, each IPPE or AWV can yield up to an additional $450 per year per patient by providing medical necessary vaccinations, procedures, screenings, counseling, labs, etc.

We would like to assist your healthcare organization in capturing this revenue while helping uncover any additional healthcare conditions your patients may have to help potentially improve their quality of life and improve their outcomes. Contact Us Today to Learn More or Get Started!

Annual Wellness Visit ROI Analysis – National

Test Name / CPT Codes Medicare Reimbursements
Initial Annual Wellness Visit / G0438 $170.00
Coginitive Assessment / 96102 & 96119 $125.00
Balance Assessment / 92548 $95.00
Alcohol Screening / G0442 $20.00
Smoking Cessation Counselling / G0436 $15.00
Obesity Counselling / G0447 $25.00
Annual Cardiovascular counseling / G0446 $25.00
Av. AWV Revenue/patient (80%) (No Counseling) $465 - $485
Addln. Office Visit / Secondary Payout $65.00
Cost per patient (Wellness Visit) $225.00
Profit for Physician per visit $240 - $320
Average monthly profit for 750 visits $20,000.00
Average monthly profit for 1000 visits $29,000.00

Add a IPPE chart or * explanation would need to provide a percentage of first year Medicare Patients

FAQs

Initial Preventive Physical Examination & Annual Wellness Exam/Annual Wellness Visit (AWV) (Q&As)

Who can perform an Annual Wellness Visit?

Medicare Part B covers the Annual Wellness Visit (AWV) if it is furnished by the following:

  • Physician (doctor of medicine or osteopathy)
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Medical professional (including a health educator, a registered dietitian, nutrition professional, or other licensed practitioner) or a team of such medical professionals working under the direct supervision of a physician (doctor of medicine or osteopathy).

CMS is not assigning particular tasks or restrictions for specific members of the team.

We believe it is better for the supervising physician to assign specific tasks to qualified team members (as long as they are licensed in the State and working within their state’s scope of practice). This approach gives the physician and the team the flexibility needed to address the beneficiary’s particular needs on a particular day. It also empowers the physician to determine whether specific medical professionals who will be working on his or her wellness team are needed on a particular day. The physician is able to determine the coordination of various team members during the AWV.

Who can perform an Initial Preventive Physical Exam?

Medicare Part B covers an Initial Preventive Physical Exam if it is furnished by the following:

  • Physician (doctor of medicine or osteopathy), or
  • Other qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist).

When is a beneficiary eligible for the Initial Preventive Physical Exam?

Medicare provides coverage of the Initial Preventive Physical Exam (IPPE) for all beneficiaries who receive the IPPE within the first 12 months after the effective date of their first Medicare Part B coverage period. This is a one-time benefit per Medicare Part B enrollee.

When is a beneficiary eligible for the Annual Wellness Visit?

Medicare provides coverage of an Annual Wellness Visit (AWV) for a beneficiary who is no longer within 12 months after the effective date of his or her first Medicare Part B coverage period and who has not received either an Initial Preventive Physical Exam (IPPE) or an AWV within the past 12 months. Medicare pays for only one first AWV per beneficiary per lifetime, and pays for one subsequent AWV per year thereafter.

Is there a way to find out whether a beneficiary previously had an Initial Preventive Physical Exam or Annual Wellness Visit and when these services were performed?

In order to verify whether the coverage requirements concerning time intervals between services have been met, you should contact the local Medicare contractor that has jurisdiction for the beneficiary. If the beneficiary has moved, you should contact the Medicare contractor where you believe the service may have been provided previously.

What is an Annual Wellness Visit (AWV)

It is a new benefit to Medicare beneficiaries as enacted by the Affordable Care Act (ACA) of 2010. Pursuant to section 4103 of the Affordable Care Act of 2010 (ACA), the Centers for Medicare & Medicaid Services expanded coverage to allow for an Annual Wellness Visit (AWV) including personalized prevention plan services (PPPS) for an individual who is no longer within 12 months of the effective date of his/her first Medicare Part B coverage period, and has not received either an initial preventive physical examination (IPPE) or an AWV with the past 12 months. Medicare coinsurance and Part B deductibles do not apply.

Why did CMS establish the AWV?

Pursuant to section 4103 of the Affordable Care Act of 2010 (ACA), the Centers for Medicare & Medicaid Services (CMS) expanded coverage to allow for an Annual Wellness Visit (AWV) including personalized prevention plan services (PPPS) for an individual who is no longer within 12 months of the effective date of his/her first Medicare Part B coverage period, and has not received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months. Medicare coinsurance and Part B deductibles do not apply.

Where can I find more information on Medicare’s Annual Wellness Visit?

The CMS has published Medicare Learning Network (MLN) Matters MM7079 based on updates to the Internet Only Manual (IOM). CMS is also updating two different IOM publications, Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 280.5, and Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1.1 and Chapter 18, Section 140.

What are the procedure codes for the AWV?

CMS has created two new codes:
G0438 – Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit
G0439 – Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit

The patient wants the AWV before it has been 12 months since the previous AWV or Initial Preventive Physical Examination (IPPE). Do need to provide the patient with an Advance Beneficiary Notice of Noncoverage (ABN)?

The timing of these services is a statutory benefit and therefore services outside the payable periods do require an ABN.

Is there a patient cost responsibility for payment of deductible and coinsurance when they receive the AWV?

Medicare does not apply deductible and coinsurance for an AWV. The patient would have no cost responsibility, unless receiving another service at the same time. Providers may need to explain this to the patient.

Is procedure code G0438, a once in a lifetime benefit?

Yes, the G0438 is the initial AWV for that patient. Any subsequent services will need to be billed using G0439.

This is the first AWV I've provided to the patient. The patient has had one previously from their former doctor. Do I use procedure code G0438 or G0439?

The correct code is G0439. The determination of whether the AWV is an initial or subsequent is based on the patient and not the person providing the service.

The guidelines on the AWV show that Medicare will allow the service once per year. Is this a 365-day year or twelve calendar months?

Medicare would look to verify that at least 11 full calendar months have passed since the last AWV.

The beneficiary just became eligible for Medicare this year. Will Medicare pay for an AWV?

In the first year of Medicare enrollment, the patient is not eligible for the AWV. Medicare can allow the IPPE (Welcome to Medicare visit) during this time. The AWV could be payable by Medicare after the first year of enrollment and only if it has been more than 11 full months following the IPPE (if the patient received the IPPE).

Is there a specific diagnosis code(s) required when billing for the AWV either initial or subsequent?

No, Medicare does not have a specific required diagnosis code. Providers would use a preventive diagnosis code.

Is there a problem if I provide a screening breast and pelvic exam on the same date as the AWV?

No. Medicare can allow both services. Please see the information in the CMS IOM, Publication 100-04, Chapter 12, Section 30.6.1.1 and 30.6.2 to determine specific billing instructions

My provider has additional service he would like to perform at the same time as the AWV. This would include the shingles vaccine, a tetanus immunization, chest x-ray, EKG, and certain blood tests. Are these things payable separately? Is a modifier required?

Each of the additional items has its own rules and regulations within Medicare. These services are not part of the AWV. If performed, the documentation must show the medical necessity for the service.

The patient is in the first year of their Medicare eligibility. I have performed a "Welcome to Medicare" visit. Next year when I provide the AWV is it an initial or subsequent?

The first AWV received by the patient is the initial. The provision of the “Welcome to Medicare” visit does not preclude billing the initial AWV G0438.

The patient scheduled the encounter for an AWV. However, once in the office, they also brought up several medical concerns. Can I bill for the AWV in addition to the medically necessary Evaluation and Management (E/M) procedure code?

Yes, a provider can bill for both services when the E/M service is significant and separately identifiable from the AWV. Providers should report modifier 25 when appropriate. Some of the components of a medically necessary E/M service may have been part of the AWV and should not be included when determining the most appropriate E/M procedure code. Please see the information in the CMS IOM Publication 100-04, Chapter 12, Section 30.6.1.1 and 30.6.2 to determine specific billing instructions.

Can a Registered Nurse or Licensed Practical Nurse perform this service and record the data?

Yes, as long as the RN or LPN is licensed and their state license allows them to perform the services. The MD/DO or a non-physician practitioner must provide direct supervision of the service when billing under a Medicare provider number.

I know that a Registered Nurse or Licensed Practical Nurse can perform the AWV under the direct supervision of an MD/DO. Can the RN perform this for a new patient?

Yes

The patient is unsure whether they have received an AWV. If I bill a subsequent AWV (G0439) with there being no initial AWV (G0438) in history, will my claim deny?

Medicare would not deny this service.

Is a provider legally required to perform an AWV or can they continue to perform the yearly physical exam.

No, Medicare does not require a provider to perform this service.

Can a physician bill Medicare for a separate visit, evaluation and management (E/M) service on the same date of service as the AWV?

When billing for an E/M and the AWV on the same date of service, the provider must remove those portions of the E/M that are included in the AWV. You cannot include any duplicative services in the coding of the E/M. Once that process is complete, you would then look to see if the E/M met the Modifier 25 guidelines – significant, separately identifiable. If the E/M is a great amount of additional work over and above what would be performed in the AWV, then you may append modifier 25 to the E/M procedure code. If it is not, then bill the AWV only.

We provided an injection or vaccination on the same day as the AWV. Does this situation require the 25 modifier?

No, this does not require a 25 modifier.

Does the Annual Wellness Visit (AWV) replace all of the preventive exam procedure codes?

No, it does not.

Is there a way for a provider to verify the date of an initial or subsequent AWV?

The Centers for Medicare & Medicaid Services (CMS) Secure Net Access Portal (C-SNAP) displays this information.

The patient's primary insurance will not accept the G0438 or G0349 procedure codes. How do we submit these charges to Medicare?

Submit the AWV codes to the primary insurance and then submit the charges to Medicare for secondary payment.

If the patient has a primary insurance, how do I bill Medicare for an Annual Wellness Visit (AWV)?

A provider should always submit the procedure code reflecting the service provided. Bill the primary insurance using the procedure code for the AWV and receive the response (payment or rejection), then subsequently bill Medicare. Medicare will process the claim based on the Medicare rules evaluating the payment from the primary insurance. However, if the primary denies because they do not recognize the procedure code, Medicare will make payment.

Learn How Care Vitality Can Make a Difference for Your Organization by Providing Annual Wellness Visit Services