Annual Wellness Visits Billing and Coding
January is Annual Wellness Visit (AWV) awareness month. Providers should encourage their patients to schedule their AWV as soon as they are able. As part of Medicare’s preventive services program, the AWV is to develop and update a prevention plan that is tailored to the patient on an ongoing basis. This program is called a Personalized Prevention Plan Service (PPPS). The AWV is not a “routine physical.” Medicare does not provide coverage for routine physicals.
Keeping patients up to date on the AWV visit helps detect early health risks and illness.
The initial AWV can be provided to a beneficiary who is no longer within their first 12 months of Medicare Part B coverage and has not received an IPPE or AWV within the previous 12 months. Medicare Part B covers the initial AWV and subsequent AWVs every 12 months. Medicare provides this benefit without any out-of-pocket costs to the Medicare patient. No deductible, copayment or coinsurance applies.
Note: The above education was developed through the A/B Medicare Administrative Contractor Provider Outreach and Education Collaboration Team. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and will assist the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.
This visit is a preventive wellness visit and not a "routine physical checkup" that some seniors may receive every year or two from their physician or other qualified nonphysician practitioner. Medicare does not provide coverage for routine physical exams.
Initial Preventive Physical Examination and Annual Wellness Visit
Initial Preventive Physical Examination
The Initial Preventive Physical Examination (IPPE) is also known as the “Welcome to Medicare” preventive visit. The goals of the IPPE are health promotion, disease prevention and detection.
Medicare pays for one beneficiary IPPE per lifetime not later than the first 12 months after the beneficiary’s eligibility date for Medicare Part B benefits.
Annual Wellness Visit and Subsequent Annual Wellness Visit
Medicare covers an Annual Wellness Visit (AWV) providing Personalized Prevention Plan Services (PPPS) for beneficiaries who:
- Are no longer within 12 months after the beneficiary’s eligibility date for Medicare Part B benefits
- Have not received an IPPE or 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
- The first Annual Wellness Visit (AWV) service must be identified with HCPCS code G0438 and subsequent AWV services with HCPCS code G0439
Documentation
- Providers may scan the patient’s clock-drawing test (CDT), but it is not required. At a minimum, the interpretation and scoring of the drawing must be documented.
Note: A clinical pharmacist (Pharm D) is considered a "medical professional." Therefore, he or she may perform the Annual Wellness Visit (AWV) if the direct supervision requirements are met. The Pharm D must be licensed in his or her state and working within his or her stated scope of practice.
- Direct Supervision: "In the office setting" means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean the physician must be present in the room when the procedure is performed.
Annual Wellness (AWV), Initial Preventative Physical Examination (IPPE) and Evaluation and Management(E/M)
When a physician or qualified nonphysician practitioner (NPP), provides a significant, separately identifiable medically necessary E/M service in addition to the Initial Preventative Physical Examination (IPPE) or an Annual Wellness Visit (AWV), CPT codes 99201 through 99215 may be reported depending on the clinical appropriateness of the circumstances.
Note: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be submitted for the medically necessary, separately identifiable, E/M service.
Review of Opioid Use During the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)
Medicare covers the following services for Medicare patients that meet certain eligibility requirements: The Initial Preventive Physical Examination (IPPE) (also known as the “Welcome to Medicare” Preventive Visit) and the Annual Wellness Visit (AWV). These preventive benefits allow you to assess your patients’ health on an annual basis to help you determine if they have any risk factors and if they are eligible for other preventive services and screenings that Medicare covers.
When reviewing the patient's medical and family history during these preventive services, Medicare would like to emphasize that review of opioid use is a routine component of this element, including opioid use disorders (OUD). If a patient is using opioids, assess the benefit from other, non-opioid pain therapies instead, even if the patient does not have OUD but is possibly at risk.
Difference Between IPPE and AWV
- Initial Preventive Physical Examination Module (Jurisdiction J and Jurisdiction M)
- Review of Opioid Use during the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) (SE18004, [PDF])
Resources