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Medicare Wellness Visits

Early detection saves lives. Encourage patients to get their preventive services.
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Updates


Note: We revised this product with the following content updates:


  • Review of current opioid prescriptions and screening for potential Substance Use Disorders (SUDs) during the Initial Preventive Physical Exam (IPPE) and Annual Wellness Visit (AWV), and making appropriate referrals for treatment
  • Medicare telehealth uses HCPCS codes G0438 and G0439

Quick Start Guide

The Annual Wellness Visits video helps health care professionals understand each of these exams and their purpose, and the requirements when submitting claims for them.

Medicare Physical Exams Coverage

Initial Preventive Physical Exam (IPPE)

Review of medical and social health history and preventive services education

Covered only once within 12 months of first Part B enrollment

Patient pays nothing (if provider accepts assignment)







Annual Wellness Visit (AWV)

Visit to develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA)

Covered once every 12 months

Patient pays nothing (if provider accepts assignment)








Routine Physical Exam

Exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury

Not covered by Medicare; prohibited by statute, however, the IPPE, AWV, or other Medicare benefits cover some elements of a routine physical

Patient pays 100% out-of-pocket


The term “patient” refers to a Medicare beneficiary.

Communication Avoids Confusion

As a health care provider, you may recommend patients get services more often than Medicare covers, including the AWV, or you may recommend services Medicare doesn’t cover. If this happens, please ensure patients understand they may pay some or all the cost. Communication is key to making sure patients understand why you’re recommending certain services, and whether Medicare pays for them.

Initial Preventive Physical Examination (IPPE)

The IPPE, known as the “Welcome to Medicare” preventive visit, promotes good health through disease prevention and detection. Medicare pays for 1 patient IPPE per lifetime not later than the first 12 months after the patient’s Medicare Part B benefits eligibility date.

1. Review the patient’s medical and social history

At a minimum, collect information about:

  • Past medical and surgical history (experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments)
  • Current medications and supplements (including calcium and vitamins)
  • Family history (review of medical events in the patient’s family, including hereditary conditions that place them at increased risk)
  • Diet
  • Physical activities
  • History of alcohol, tobacco, and illegal drug use

Get more information about Medicare Substance Use Disorder (SUD) services coverage in the Screening, Brief Intervention, & Referral to Treatment (SBIRT) Services booklet.

2. Review patient’s potential depression risk factors, including current or past experiences with depression or other mood disorders

Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. Find more information on depression screening on the Depression Assessment Instruments website.

3. Review patient’s functional ability and safety level

Use direct patient observation, or appropriate screening questions or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, these areas:

  • Ability to perform Activities of Daily Living (ADLs)
  • Fall risk
  • Hearing impairment
  • Home safety

4. Exam

Measure:

  • Height, weight, Body Mass Index (BMI) (or waist circumference, if appropriate), and blood pressure
  • Visual acuity screen
  • Other factors deemed appropriate based on medical and social history and current clinical standards

5. End-of-life planning, on patient agreement

End-of-life planning is verbal or written information offered to the patient about:

  • Their ability to prepare an advance directive in case an injury or illness prevents them from making health care decisions
  • If you agree to follow their wishes expressed in an advance directive

6. Review current opioid prescriptions

For a patient with a current opioid prescription:

  • Review their potential Opioid Use Disorder (OUD) risk factors
  • Evaluate their pain severity and current treatment plan
  • Provide information on non-opioid treatment options
  • Refer to a specialist, as appropriate

Get more information on pain management in the HHS Pain Management Best Practices Inter-agency Task Force Report.

7. Screen for potential Substance Use Disorders (SUDs)

Review the patient’s potential risk factors for SUDs and, as appropriate, refer them for treatment. A screening tool isn’t required but you may use one. Find more information on the National Institute on Drug Abuse Screening and Assessment Tools Chart.

8. Educate, counsel, and refer based on previous components

Based on the results of the review and evaluation services in the previous components, give appropriate education, counseling, and referral.

9. Educate, counsel, and refer for other preventive services

Includes a brief written plan, such as a checklist, for the patient to get:

  • A once-in-a-lifetime screening electrocardiogram (ECG/EKG), as appropriate
  • Appropriate screenings and other preventive services Medicare covers in the AWV

Use these HCPCS codes to file IPPE and ECG/EKG screening claims:

IPPE HCPCS Codes & Descriptors

G0402

Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment

G0403

Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

G0404

Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

G0405

Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

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

* Get more information on how to bill HCPCS code G0468 in the Medicare Claims Processing Manual, Chapter 9, Section 60.2.

Diagnosis

You must report a diagnosis code when submitting an IPPE claim. Medicare doesn’t require you to document a specific IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Billing

Medicare Part B covers an IPPE when 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])

When you provide an IPPE and a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service, Medicare may pay the additional service. Report the additional CPT code (99201–99215) 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.

CPT only copyright 2020 American Medical Association. All rights reserved.

 

Annual Wellness Visit (AWV) Health Risk Assessment (HRA)

The AWV includes a HRA. See summary below of the minimum elements in the HRA. Get more information in the CDC’s A Framework for Patient-Centered Health Risk Assessments booklet, including:

  • Evidence suggests HRA use and follow-up interventions can positively influence health behaviors
  • Definition of the HRA framework and rationale for its use
  • Guidance on HRA use, reduction of health disparities, and improving health outcomes through identifying modifiable health risks and providing behavior change interventions
  • Sample HRA

Perform Health Risk Assessment (HRA)

  • Get patient self-reported information
    • You or the patient complete the HRA before or during the AWV; it shouldn’t take more than 20 minutes
  • Consider the best way to communicate with underserved populations, people with limited English proficiency, health literacy needs, and persons with disabilities
  • At a minimum, collect information about:
    • Demographic data
    • Health status self-assessment
    • Psychosocial risks including but not limited to depression/life satisfaction, stress, anger, loneliness/social isolation, pain, and fatigue
    • Behavioral risks including but not limited to tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle (for example, seat belt use), and home safety
    • Activities of Daily Living (ADLs) including dressing, feeding, toileting, grooming, physical ambulation including balance/risk of falls and bathing; and Instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, mode of transportation, shopping, managing medications, and handling finances

1. Establish patient’s medical and family history

At a minimum, document:

  • Medical events of the patient’s parents, siblings, and children including hereditary conditions that place them at increased risk
  • Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments
  • Use of, or exposure to, medications and supplements, including calcium and vitamins

2. Establish list of current providers and suppliers

Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.

3. Measure

Measure:

  • Height, weight, Body Mass Index (BMI) (or waist circumference, if appropriate), and blood pressure
  • Other routine measurements deemed appropriate based on medical and family history

4. Detect any cognitive impairment patients may have

Assess cognitive function by direct observation, considering information from the patient, family, friends, caregivers, and others. Consider using a brief cognitive test, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Find more information on the National Institute on Aging’s Alzheimer’s and Dementia Resources for Professionals website.

5. Review patient’s potential depression risk factors, including current or past experiences with depression or other mood disorders

Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. Find more information on depression screening on the Depression Assessment Instruments website.

6. Review patient’s functional ability and level of safety

Use direct patient observation, or appropriate screening questions or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, these areas:

  • Ability to perform Activities of Daily Living (ADLs)
  • Fall risk
  • Hearing impairment
  • Home safety

7. Establish an appropriate written screening schedule for patients, such as a checklist for next 5–10 years

Base written screening schedule on the:

8. Establish list of patient risk factors and conditions where primary, secondary, or tertiary interventions are recommended or underway

Include:

  • Mental health conditions including depression, substance use disorder(s), and cognitive impairment
  • IPPE risk factors or conditions identified
  • Treatment options and associated risks and benefits

9. Provide patient’s personalized health advice and appropriate referrals to health education or preventive counseling services or programs

Include referrals to educational and counseling services or programs aimed at:

  • Community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including:
    • Fall prevention
    • Nutrition
    • Physical activity
    • Tobacco-use cessation
    • Weight loss
    • Cognition

10. Provide Advance Care Planning (ACP) services at patient’s discretion

ACP is a discussion between you and the patient about:

  • Their preparation of an advance directive in case an injury or illness prevents them from making health care decisions
  • Future care decisions they might need to make
  • How they can let others know about care preferences
  • Caregiver identification
  • Explanation of advance directives, which may involve completing standard forms

“Advance directive” is a general term referring to various documents such as a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent and/or records a person’s wishes about their medical treatment used at a future time when the individual is unable to speak for themselves. Get more information in the Advance Care Planning fact sheet.

11. Review current opioid prescriptions

For a patient with a current opioid prescription:

  • Review their potential Opioid Use Disorder (OUD) risk factors
  • Evaluate their pain severity and current treatment plan
  • Provide information on non-opioid treatment options
  • Refer to a specialist, as appropriate

Get more information on pain management in the HHS Pain Management Best Practices Inter-agency Task Force Report.

12. Screen for potential Substance Use Disorders (SUDs)

Review the patient’s potential risk factors for SUDs and, as appropriate, refer them for treatment. A screening tool isn’t required but you may use one. Find more information in the National Institute on Drug Abuse Screening and Assessment Tools Chart.

 

1. Review and update Health Risk Assessment (HRA)

  • Get patient self-reported information
    • You or the patient can update the HRA before or during the AWV; it shouldn’t take more than 20 minutes
  • At a minimum, collect information about:
    • Demographic data
    • Health status self-assessment
    • Psychosocial risks including but not limited to depression/life satisfaction, stress, anger, loneliness/social isolation, pain, and fatigue
    • Behavioral risks including but not limited to tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle (for example, seat belt use), and home safety
    • Activities of Daily Living (ADLs) including dressing, feeding, toileting, grooming, physical ambulation including balance/risk of falls and bathing; and Instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, mode of transportation, shopping, managing medications, and handling finances

2. Update patient’s medical and family history

At a minimum, update and document:

  • Medical events of the patient’s parents, siblings, and children including hereditary conditions that place them at increased risk
  • Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments
  • Use of, or exposure to, medications and supplements, including calcium and vitamins

3. Update list of current providers and suppliers

Include current patient providers and suppliers that regularly provide medical care, including those added because of the first AWV Personalized Prevention Plan Services (PPPS), and any behavioral health providers.

4. Measure

Measure:

  • Weight (or waist circumference, if appropriate) and blood pressure
  • Other routine measurements deemed appropriate based on medical and family history

5. Detect any cognitive impairment patients may have

Assess cognitive function by direct observation, considering information from the patient, family, friends, caregivers, and others. Consider using a brief cognitive test, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Find more information on the National Institute on Aging’s Alzheimer’s and Dementia Resources for Professionals website.

6. Update patient’s written screening schedule

Base written screening schedule on the:

7. Update patient’s list of risk factors and conditions where primary, secondary, or tertiary interventions are recommended or underway

Include:

  • Mental health conditions including depression, substance use disorder(s), and cognitive impairment
  • Risk factors or conditions identified
  • Treatment options and associated risks and benefits

8. As necessary, provide and update patient’s PPPS, which includes personalized patient health advice and referral(s) to health education or preventive counseling services or programs when needed

Include referrals to educational and counseling services or programs aimed at:

  • Community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including:
    • Fall prevention
    • Nutrition
    • Physical activity
    • Tobacco-use cessation
    • Weight loss
    • Cognition

9. Provide Advance Care Planning (ACP) services at patient’s discretion

ACP is a discussion between you and the patient about:

  • Their preparation of an advance directive in case an injury or illness prevents them from making health care decisions
  • Future care decisions they might need to make
  • How they can let others know about care preferences
  • Caregiver identification
  • Explanation of advance directives, which may involve completing standard forms

“Advance directive” is a general term referring to various documents such as a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent and/or records a person’s wishes about their medical treatment used at a future time when the individual is unable to speak for themselves. Get more information in the Advance Care Planning fact sheet.

10. Review current opioid prescriptions

For a patient with a current opioid prescription:

  • Review their potential Opioid Use Disorder (OUD) risk factors
  • Evaluate their severity of pain and current treatment plan
  • Provide information on non-opioid treatment options
  • Refer to a specialist, as appropriate

Get more information on pain management in the HHS Pain Management Best Practices Inter-agency Task Force Report.

11. Screen for potential Substance Use Disorders (SUDs)

Review the patient’s potential risk factors for SUDs and, as appropriate, refer them for treatment. A screening tool isn’t required but you may use one. Find more information in the National Institute on Drug Abuse Screening and Assessment Tools Chart.


Coding

Use these HCPCS codes to file AWV claims:

AWV HCPCS Codes and Descriptors

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

* Get more information on how to bill HCPCS code G0468 in the Medicare Claims Processing Manual, Chapter 9, Section 60.2.


Diagnosis

Report a diagnosis code when submitting an AWV claim. Since Medicare doesn’t require you to document a specific AWV diagnosis code, you may choose any diagnosis code consistent with the patient’s exam.

Billing

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

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.

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. Remember, you must not 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.”

Medicare telehealth uses HCPCS codes G0438 and G0439. Get more information on the List of Telehealth Services webpage.

CPT only copyright 2020 American Medical Association. All rights reserved.


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.

Coding

Use these CPT codes to file ACP claims as an optional AWV element:

ACP CPT Codes and Descriptors

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

99498

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; each additional 30 minutes (List separately in addition to code for primary procedure)

Diagnosis

You must report a diagnosis code when submitting an ACP claim as an optional AWV element. Since Medicare doesn’t require you to document a specific ACP diagnosis code as an optional AWV element, you may choose any diagnosis code consistent with a patient’s exam.

Billing

Medicare waives both the ACP coinsurance and the Medicare Part B deductible when:

  • Provided on the same day as the covered AWV
  • Provided by the same provider as the covered AWV
  • Billed with modifier –33 (Preventive Service)
  • Billed on the same claim as the AWV

Medicare waives the ACP deductible and coinsurance once per year when billed with the AWV. If the AWV billed with ACP is denied for exceeding the once-per-year limit, Medicare will apply the ACP deductible and coinsurance.

The deductible and coinsurance apply when you deliver the ACP outside of the covered AWV. There are no limits on the number of times you can report ACP for a certain patient in a certain time period. When billing this patient service multiple times, document the change in the patient’s health status and/or wishes regarding their end-of-life care.

Preparing Eligible Medicare Patients for the AWV

Providers can help eligible Medicare patients prepare for their AWV by encouraging them to bring the following information:

  • Medical records, including immunization records
  • A detailed family health history
  • A full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
  • A full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals) and behavioral health specialists

CPT only copyright 2020 American Medical Association. All rights reserved.

IPPE, AWV, & Routine Physical – Know the Differences

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.

AWV

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

Exam 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
  • Patient pays 100% out-of-pocket

AWV/IPPE FAQs

  • Advance Care Planning (ACP) as an Optional AWV Element
  • Alcohol Misuse Screening & Counseling
  • Annual Wellness Visit (AWV)
  • Bone Mass Measurements
  • Cardiovascular Disease Screening Tests
  • Colorectal Cancer Screening
  • Counseling to Prevent Tobacco Use
  • Depression Screening
  • Diabetes Screening
  • Diabetes Self-Management Training (DSMT)
  • Flu, Pneumococcal, & Hepatitis B Shots and their Administration
  • Glaucoma Screening
  • Hepatitis B Screening
  • Hepatitis C Screening
  • Human Immunodeficiency Virus (HIV) Screening
  • Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
  • IBT for Obesity
  • Initial Preventive Physical Examination (IPPE)
  • Lung Cancer Screening
  • Medical Nutrition Therapy (MNT)
  • Medicare Diabetes Prevention Program (MDPP)
  • Prolonged Preventive Services
  • Prostate Cancer Screening
  • Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests
  • Screening for Sexually Transmitted Infections (STIs) & High Intensity Behavioral Counseling (HIBC) to Prevent STIs
  • Screening Mammography
  • Screening Pap Tests
  • Screening Pelvic Examination (includes a clinical breast examination)
  • Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)

Find more information on each Medicare preventive service in the MLN’s Medicare Preventive Services educational tool.


No. The IPPE isn’t a routine physical that some older adults may get periodically from their physician or other qualified Non-Physician Practitioner (NPP). The IPPE is an introduction to Medicare and covered benefits and focuses on health promotion, disease prevention, and detection to help patients stay well. We encourage providers to inform patients about the AWV and perform such visits. The SSA explicitly prohibits Medicare coverage for routine physical examinations.


No. The AWV isn’t a routine physical that some older adults may get periodically from their physician or other qualified NPP. Medicare doesn’t cover routine physical examinations.


No. The IPPE and AWV don’t include clinical laboratory tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.


No. Medicare waives both the coinsurance/copayment and the Medicare Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening electrocardiogram (ECG/EKG) (HCPCS codes G0403, G0404, or G0405).


No. Medicare waives the AWV coinsurance or copayment and the Medicare Part B deductible.


A patient who hasn’t had an IPPE and whose initial enrollment in Medicare Part B began in 2020 is eligible for an IPPE in 2021 as long as it’s within 12 months of the patient’s first Medicare Part B enrollment effective date.

We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, contact your MAC.


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.


Generally, you may provide other medically necessary services on the same date as an AWV. The deductible and coinsurance or copayment apply for these other medically necessary and reasonable services.


You have different options for accessing AWV eligibility information depending on where you practice. You may access the information through the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS) or through the provider call center Interactive Voice Responses (IVRs).

We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, contact your MAC.


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