Medicare pays a physician for an Annual Wellness Visit (AWV) service. This visit is planned to develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA) which is covered once every 12 months by Medicare. Medicare covers an AWV for all patients who aren’t within 12 months after the eligibility date for their first Medicare Part B benefit period and who didn’t have an IPPE or an AWV within the past 12 months. Medicare pays for only 1 IPPE per patient per lifetime and 1 additional AWV per year thereafter. Medicare also waives the AWV coinsurance or co-payment and the Medicare Part B deductible.
Differentiating IPPE, AWV, and Routine Physical Exam
IPPE : The IPPE, known as the ‘Welcome to Medicare’ preventive visit, promotes good health through disease prevention and detection. Medicare pays 1 patient IPPE per lifetime not later than the first 12 months after the patient’s Medicare Part B benefits eligibility date. Medicare pays the IPPE costs if the provider accepts assignment.
AMW : Medicare covers an AWV that delivers Personalized Prevention Plan Services (PPPS) for patients who:
- Aren’t within 12 months after the patient’s first Medicare Part B benefits eligibility date
- Didn’t get an IPPE or AWV within the past 12 months
- Medicare pays the AWV costs if the provider accepts assignment and the deductible doesn’t apply
Routine Physical Exam : Routine Physical Exam is performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury. Medicare doesn’t cover the routine physical; it’s prohibited by statute, but Medicare covers some elements of a routine physical under the IPPE, the AWV, or other Medicare benefits where patient pays 100% out-of-pocket.
Billing for Medicare Annual Wellness Visit (AWV)
Medicare Part B covers an AWV if performed by a:
- Physician (a Doctor of Medicine or Osteopathy)
- Qualified Non-Physician Practitioner (NPP) (a Physician Assistant [PA], Nurse Practitioner [NP], or Certified Clinical Nurse Specialist [CCNS])
- Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of medical professionals directly supervised by a physician.
Applicable HCPCS codes to file AWV are as:
- 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 an IPPE or AWV.
You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV and G0439 is for subsequent AWVs. You can’t bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. Medicare denies these claims with messages of ‘Benefit maximum for this time period or occurrence has been reached’ and ‘Consult plan benefit documents/guidelines for information about restrictions for this service.’ When you provide an AWV and a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service, Medicare may pay the additional service. Report the additional CPT code with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury, or to improve the functioning of a malformed body part.
Advance Care Planning (ACP)
Advance Care Planning (ACP) is an optional AWV element. ACP is the face-to-face conversation between a Medicare physician (or other qualified health care professional) and a patient to discuss their health care wishes and medical treatment preferences if they become unable to speak or make decisions about their care. At the patient’s discretion, you can provide the ACP at the time of the AWV. Procedure codes for ACP are:
- CPT Code 99497: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
- CPT Code 99498: for each additional 30 minutes (list separately in addition to code for primary procedure)
CPT copyright 2022 American Medical Association.
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