Why the Need for a Wellness Visit Program?
The Welcome to Medicare (IPPE) and Annual Wellness Visit (AWV) is a comprehensive preventative care visit to discuss your patient’s health and develop a prevention and wellness plan. These visits are different from an annual physical. Wellness Visits are designed to prevent disease and help your patients stay active and healthy as long as possible.
Medicare Part B patients pay nothing for the “Welcome to Medicare” preventive visit or the yearly “Wellness” visit if the doctor or other qualified health care provider accepts assignment.
However, patients may have to pay coinsurance, and the Part B deductible may apply if:
• You perform additional tests or services during the same visit.
• These tests or services are not covered under the preventive benefits.
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 184.108.40.206 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 220.127.116.11 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 18.104.22.168 and 30.6.2 to determine specific billing instructions.
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.
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