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Billing and coding for the medicare annual wellness visits.

Services provided during all three types of AWVs involve establishing and/or updating patient records with essential vital signs, personal and family health status and history, medications and indications.  Physicians can help patients get ready for their AWV by encouraging them to come prepared with the following information:

• Medical Records, including immunization records
• Family health history with as much detail as possible
• Full list of current medications--including calcium, vitamins and over-the-counter products–and dosage and frequency for each
• Full list of current providers and suppliers involved in providing care

  Three Visits With Three Sets Of Requirements

  1.)    G0402 – Initial preventive physical examination, face to face with patient, this service is for new Medicare beneficiaries and must be performed within the first 12-months of Medicare Enrollment. This is not a physical exam, even though the physician does measure and record basic vitals, but the patient is also eligible for an EKG screening (electrocardiograph--G0403-G0405) and aortic aneurism ultrasound (AAU) if they meet certain guidelines for these services.  Often referred to as the “Welcome to Medicare Physical,” this benefit is only payable once during an enrollee’s lifetime.  If a patient does not take advantage of the Welcome To Medicare visit within their first year of Medicare enrollment, they lose the Welcome Visit benefit, and it can never be recovered.

For more details on EKG and AAU screenings , please visit the CMS website.  

2.)    G0438 – Annual Wellness visit: Initial visit, includes a personalized prevention plan of care (PPPS).  Once a patient has had the Welcome to Medicare Visit, 11 full months must pass before the patient is eligible for the Annual Wellness Visit, Initial Visit.  This visit can be preformed any time in the patient’s life, but can only be performed once .  If a patient did not have the “Welcome to Medicare” visit within that first year of Medicare enrollment, they are still eligible for the Initial Annual Wellness Visit at any point in their life.

At the Initial Annual Wellness Visit, the health care provider will perform all of the key components of the visit, and record and discuss findings with the patient.  Together, the provider and patient will devise a wellness plan and screening schedule intended to aid in maintaining or improving the health of the patient.  The key elements include:

• Establishment of the patient’s medical/family history
• Measurement of the patient’s height, weight, BMI (body mass index), blood pressure, and other routine measurements as deemed appropriate, based on patient’s medical and family history
• List of current providers and suppliers (diabetic supplies, etc) that are regularly providing care
• Detection of any cognitive impairments the patient may have
• Review of a patient’s potential risk factors for depression
• Review of the patient’s functional ability and level of safety, based on direct observation of the patient
• Establishment of written screening schedule for the patient, such as a checklist for the next 5-10 years
• Establishment of a list of risk factors and conditions against which primary, secondary, or tertiary interventions are recommended or underway for the patient, including any mental health conditions or any such risk factors or conditions that have been indentified through an initial preventive physical exam (IPPE), and a list of treatment options and their associated risks and benefits
• Provision of personalized health advice to the patient and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management or community-based lifestyle interventions to reduce health risks, and promote self-management and wellness.

3.)    G0439 – Annual Wellness visit: Subsequent visit, includes personalized prevention plan (PPPS).   After 11 full months have passed since the patient’s Initial Annual Wellness Visit ( G0438), the patient becomes eligible for the “Subsequent” Wellness Visit(s).  The patient can request this visit every year, after a full 11 months have passed .  The key elements performed during the Subsequent Annual Wellness Visits include:

• Updating of the patient’s medical/family history
• Updating of the list of the patient’s current medical providers and suppliers that are regularly involved in providing medical care to the patient, as was developed in the first Annual Wellness Visit (AWV), providing PPPS
• Updating of the patient’s written screening schedule as developed at the first AWV, providing PPPS
• Updating of the list of risk factors and conditions of which primary, secondary, or tertiary interventions are recommended or underway for the patient, as was developed at the first AWV, providing PPPS.
• Furnishing appropriate personalized health advice to the patient and a referral, as appropriate, to health education or preventive counseling services or programs

These preventive wellness benefits were designed by CMS to follow a logical progression in managing the health of Medicare enrollees.  There is a well-defined “introductory” visit, which is the Welcome To Medicare Visit, G0402; followed 11 months later by the Initial Annual Wellness Visit, G0438, and the Subsequent Annual Wellness Visits, G0439, to follow at intervals of roughly one year.  It’s actually a much simpler progression than it often gets credit for, and, once understood, proves to be a valuable tool for enabling providers to collaborate effectively with their mature patients on improving and maintaining good health for a longer life. You can find a summary of the requirements of all Medicare Wellness Visits on the CMS website.

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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.

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Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS)

The Affordable Care Act provides for an Annual Wellness Visit (AWV), including Personalized Prevention Plan Services (PPPS) for Medicare beneficiaries as of January 1, 2011. CR 7079 provides the requirements for the AWV, which are summarized in this article. Make sure billing staff are aware of these services and how to bill for them.

Download the Guidance Document

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: February 15, 2011

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

Confusion about the Medicare annual wellness visit

Since its debut last year, the Medicare annual wellness visit (AWV) has been an apparent source of ongoing confusion. That point was driven home to me again this week after I reviewed some Medicare claims data for this service.

As a reminder, there are two codes related to the AWV:  G0438 (includes a personalized prevention plan of service, initial visit) and G0439 ( includes a personalized prevention plan of service, subsequent visit). As the descriptors imply, the initial AWV, should precede a subsequent AWV, and at least 11 months should have elapsed since the month of the initial AWV before a subsequent AWV can be performed and billed.

Both services became Medicare benefits effective Jan. 1, 2011. In 2011, Medicare paid for G0439 (subsequent AWV) more than 50,000 times. Given the timing of the two services and given that a Medicare beneficiary could not receive G0438 (initial AWV) before Jan. 1, 2011, it is not clear how or why any claims for a subsequent AWV (G0439) would have been processed in 2011.

I suspect that G0439 was being reported in 2011 because of confusion regarding its relationship to the Initial Preventive Physical Exam (IPPE, also known as the "Welcome to Medicare Visit"), code G0402. As noted in " When A Medicare Annual Wellness Visit Follows a Welcome to Medicare Physical ," FPM , May/June 2012, "The initial annual wellness visit must take place before a subsequent annual wellness visit in order to establish the required components that will be updated at subsequent visits. The initial annual wellness visit must occur no earlier than the same month of the year following the IPPE." In other words, the inital AWV follows an IPPE and a subsequent AWV follows an initial AWV.

Why the Medicare contractors reimbursed for G0439 in 2011 is a mystery. Apparently, they do not have the capacity or edits in place to recognize when a subsequent AWV is billed erroneously instead of an initial AWV.

For physician practices, this is more than just a matter of miscoding. It is also a matter of lost revenue. Medicare's average allowance for G0438 is $166; for G0439, it is approximately $111. That means that every time you bill G0439 when you should have billed G0438, you are leaving about $55 on the table. Maybe that's why the Medicare carriers were happy to process G0439 claims in 2011.

For more information on the AWV, check out the FPM Topic Collection on Medicare Annual Wellness Visits . 

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0176-Annual Wellness Visit: Incorrect Coding

Description

Claims for HCPCS code G0402- Initial Preventative Physical Examination (IPPE), may not be billed more than 12 months after the effective date of the beneficiary’s first part B coverage, or more than once in a lifetime. Claims for HCPCS code G0438- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); initial, may not be billed more than once in a lifetime. Claims for HCPCS code G0439- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); subsequent, may not be billed within 12 months of G0438 or G0439. 

Affected Code(s)

G0402, G0438, G0439

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (s)(2)(W)- an initial preventive physical exam 3.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (s)(2)(FF)- Medical and other health services- personalized prevention plan services 4.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (ww)- Initial Preventive Physical Examination 5.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (hhh)-Annual Wellness Visit 6.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 7.    42 CFR §405.929- Post-Payment Review 8.    42 CFR §405.930- Failure to Respond to Additional Documentation Request 9.    42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 10.    42 CFR §405.986- Good Cause for Reopening   11.    42 CFR §410.15 - Annual Wellness Visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage 12.    42 CFR §410.16-Initial Preventative Physical Examination: Conditions for and limitations on coverage 13.    Medicare Benefit Policy Manual- Chapter 15- Covered Medical and Other Health Services, §280.5- Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS) 14.    Medicare Claims Processing Manual- Chapter 12- Physicians/Nonphysician Practitioners, §30.6.1.1 Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV] 15.    Medicare Claims Processing Manual- Chapter 18- Preventive and Screening Services, §140- Annual Wellness Visit 16.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 17.    AMA HCPCS/CPT Codebook