FAQs for Medicare Wellness Visits / Annual Wellness Visit (AWV)

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 provider 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 wellness visit.

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).

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.

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.

n 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.

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.

An annual physical exam is a more extensive screening. It involves a physical exam by a doctor and includes bloodwork and other tests to assess any health risks. Annual wellness visits can include bloodwork and will check routine measurements such as height, weight, and blood pressure.

The Medicare wellness visit focuses on preventing disease and disability by creating a “personalized prevention plan” for potential future medical issues based on the beneficiary’s health and their other risk factors

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.

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.

CMS has created two new codes:

• G0438 – Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) for first visits
• G0439 – Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit

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

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 information to the patient.

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

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

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

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

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

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

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.

Medicare would not deny this service.

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

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.

No, this does not require a 25 modifier.

No, it does not.

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

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.

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