G0438  Annual Wellness Visit (AWV); includes a personalized prevention plan (PPPS)  

This code can only be used for a beneficiary who is no longer within the first twelve  months after the effective date of Part B coverage; and if he/she has not already  received either an IPPE or an AWV within the past twelve months.  Medicare pays  for only one Initial Annual Wellness Visit per beneficiary per lifetime; all  subsequent wellness visits must be billed as a Subsequent  annual Wellness Visit  (G0439).

G0439 Subsequent Annual Wellness Visit (AWV); includes a personalized prevention plan  (PPPS)

This code is to be used in the years subsequent to the submission of G0438 for the initial annual wellness visit, even if the patient switches to a new doctor.  (See MLM  Matters number MM7079 for details.)


E&M service during the same encounter as an IPPE or AWV: 

When the physician provides a significant,+separately+identifiable medically necessary E&M  service in addition to the IPPE or AWV, CPT codes 99201>99215 may be reported depending on  the clinical appropriateness of the circumstances.  CPT modifier >25 must be  deppended to the  medically necessary E&M service identifying this service as a significant, separately identifiable  service from the IPPE or AWV code reported (G0402, G0438 or G0439 whichever applies). 

What is the IPPE ?

• One-time visit, covered within first 12 months of Part B enrollment and includes –
• Review of medical and social history
• Review of potential (risk factors) for depression
• Review of functional ability and level of safety
• Measurement of height, weight, body mass index, blood pressure, visual acuity screen, and other factors deemed appropriate
• Discussion of end-of-life planning, upon agreement of the individual
• Education, counseling and referrals based on results of review and evaluation services performed during the visit, including a brief written plan such as a checklist, and if appropriate, education, counseling and referral for obtaining an electrocardiogram (a/k/a EKG, ECG)

Who Can Provide an IPPE ?

Physician (doctor of medicine or osteopathy)

• Qualified non-physician practitioner:
• Nurse practitioner
• Physician assistant
• Clinical nurse specialist

Who can bill for the IPPE?

These services typically are provided in a physician office. When the services are provided in a facility, the following institutions can bill:
o Hospitals for inpatients (TOB 12X) and outpatients (TOB 13x)
o Skilled Nursing Facilities for inpatients (TOB 22X)
o Rural Health Centers (TOB 71X)
o Federally Qualified Health centers (TOB 77X)
o Critical Access Hospitals (TOB 85X)

Although a diagnosis code must be reported on the claim, there are no specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes that are required for the IPPE; therefore, Medicare providers should chose an appropriate ICD-9-CM diagnosis code.

IPPE-Related Screening for Abdominal Aortic Aneurysm (AAA)

A one-time only ultrasound screening for an Abdominal Aortic Aneurysm (AAA) can be done as the result of a referral from an IPPE for Medicare beneficiaries with certain risk factors. The code for billing the AAA ultrasound screening is below:

G0389 – Ultrasound, B-scan and or real time with image documentation; AAA screening Preparing Patients for the IPPE

Stephanie Frilling

Providers can help Medicare beneficiaries get ready for their IPPE by encouraging them to come prepared with the following information:
• Medical records, including immunization records;
• Family health history, in as much detail as possible; and
• A full list of medications and supplements, including calcium and vitamins – how often and how much of each is taken. Who Can Provide an AWV *
• A “health professional” meaning a:
• Physician
• Physician assistant
• Nurse practitioner
• Clinical nurse specialist
• Medical professional (including a health educator, a registered dietitian, or nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician

The following G-codes identify the AWV for Medicare payment:
• G0438 (Annual wellness visit, including Personalized Prevention Plan Service, first visit), and
• G0439 (Annual wellness visit, including Personalized Prevention Plan Service, subsequent visit). Who can bill for the AWV*

These services typically are provided in a physician office. When the services are provided in
a facility, the following institutions can bill:
o Hospital inpatients (TOB 12X) and outpatients (TOB 13x)
o Skilled Nursing Facilities inpatients (TOB 22X) and outpatients (23X)
o Rural Health Centers (TOB 71X)
o Federally Qualified Health centers (TOB 77X)
o Critical Access Hospitals (TOB 85X)

Note: Medicare makes a single fee schedule payment for a beneficiary’s AWV when provided in a physician office or hospital outpatient department

Diagnosis Coding

• Although a diagnosis code must be reported on the claim, there are no specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes that are required for the AWV; therefore, Medicare providers should chose an appropriate ICD-9-CM diagnosis code or contact the local Medicare contractor for guidance.

Preparing Patients for the AWV Stephanie Frilling

Providers can help Medicare beneficiaries get ready for their AWV by encouraging them to come prepared with the following information:
• Medical records, including immunization records;
• Family health history, in as much detail as possible;
• A full list of medications and supplements, including calcium and vitamins – how often and how much of each is taken; and
• A full list of current providers and suppliers involved in providing care.

Medicare complete Guide for Annual 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 effective date of their first Medicare Part B coverage period
* Have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months

This publication is divided into two sections: the first explains the elements of a beneficiary’s initial AWV; the second explains the elements of all subsequent AWVs. You must provide all elements of the AWV prior to submitting a claim for the AWV.

Acquire Beneficiary Information

Action Elements

Administer HRA * Collect self-reported information from the beneficiary You or the beneficiary can complete the HRA before or during the AWV encounter; it should take no more than 20 minutes

* Account for and tailor to the communication needs of underserved populations, persons with limited English proficiency, and persons with health literacy needs

* At a minimum, address the following topics:

Demographic data Self-assessment of health status
Psychosocial risks
Behavioral risks

Activities of Daily Living (ADLs), including but not limited to: dressing, bathing, and walking

Instrumental ADLs, including but not limited to: shopping, housekeeping, managing own medications, and handling finances Establish a list of current providers and suppliers

Include current providers and suppliers that regularly provide medical care to the beneficiary Establish the beneficiary’s medical/family history

At a minimum, collect and document the following:

* Medical events of the beneficiary’s parents, siblings, and children, including diseases that may be hereditary or place the beneficiary 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

Review the beneficiary’s potential risk factors for depression, including current or past experiences with depression or other mood disorders

Use any appropriate screening instrument for beneficiaries without a current diagnosis of depression, which you may select from various available standardized screening tests designed for this purpose and recognized by national professional medical organizations Review the beneficiary’s functional ability and level of safety

Use direct observation of the beneficiary, or select appropriate screening questions or a screening questionnaire from various available screening questions or standardized questionnaires recognized by national professional medical organizations to assess, at a minimum, the following topics:

* Ability to successfully perform ADLs
* Fall risk
* Hearing impairment
* Home safety Counsel Beneficiary Action Elements

Establish a written screening schedule for the beneficiary, such as a checklist for the next 5 to 10 years, as appropriate

Base written screening schedule on:
* Age-appropriate preventive services Medicare covers
* Recommendations from the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP)
* The beneficiary’s HRA, health status and screening history, and age-appropriate preventive services covered by Medicare Establish a list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended or underway for the beneficiary

Include the following:
* Mental health conditions
* Risk factors or conditions identified through an IPPE
* Treatment options and their associated risks and benefits

Furnish personalized health advice to the beneficiary 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 selfmanagement and wellness, including:

Fall prevention Nutrition Physical activity Tobacco-use cessation Weight loss Furnish, at the discretion of the beneficiary, advance care planning services

Include discussion about:

* Future care decisions that may need to be made
* How the beneficiary can let others know about care preferences
* Explanation of advance directives, which may involve the completion of standard forms Acquire Updated Beneficiary Information

Action Elements

Update HRA * Collect self-reported information from the beneficiary You or the beneficiary can update the HRA before or during the AWV encounter; it should take no more than 20 minutes

* At a minimum, address the following topics:

Demographic data

Self-assessment of health status

Psychosocial risks Behavioral risks

ADLs, including but not limited to: dressing, bathing, and walking

Instrumental ADLs, including but not limited to: shopping, housekeeping, managing own medications, and handling finances Update the list of current providers and suppliers

Include current providers and suppliers regularly involved in providing medical care to the beneficiary Update the beneficiary’s medical/family history

At a minimum, update and document the following:

* Medical events of the beneficiary’s parents, siblings, and children, including diseases that may be hereditary or place the beneficiary 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 Assess Obtain the following measurements:
* Weight (or waist circumference, if appropriate) and blood pressure
* Other routine measurements as deemed appropriate based on medical and family history Detect any cognitive impairment the beneficiary may have

Assess the beneficiary’s cognitive function by direct observation, with due consideration of information obtained via beneficiary reports and concerns raised by family members, friends, caretakers, or othersCounsel Beneficiary Action Elements Update the written screening schedule for the beneficiary

Base written screening schedule on:
* Age-appropriate preventive services Medicare covers
* Recommendations from the USPSTF and the ACIP
* The beneficiary’s HRA, health status and screening history, and age-appropriate

preventive services covered by Medicare Update the list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or underway for the beneficiary

Include the following:
* Mental health conditions
* Risk factors or conditions identified
* Treatment options and their associated risks and benefits

Action Elements Furnish personalized health advice to the beneficiary and a referral, as appropriate, 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 selfmanagement and wellness, including:

Fall prevention Nutrition Physical activity Tobacco-use cessation Weight loss Furnish, at the discretion of the beneficiary, advance care planning services

Include discussion about:

* Future care decisions that may need to be made
* How the beneficiary can let others know about care preferences
* Explanation of advance directives, which may involve the completion of standard forms Use the following HCPCS codes to file claims for AWVs.

AWV HCPCS Codes and Descriptors
AWV HCPCS Codes Billing Code 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 Diagnosis

You must report a diagnosis code when submitting a claim for the AWV. Since you are not required to document a specific diagnosis code for the AWV, you may choose any diagnosis code consistent with the beneficiary’s exam.

Billing Medicare Part B covers an AWV if performed by a:

* Physician (a doctor of medicine or osteopathy)

* Qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist)

* Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of medical professionals who are directly supervised by a physician (doctor of medicine or osteopathy) When you furnish a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service along with the AWV, Medicare may pay for the additional service. Report the additional Current Procedural Terminology (CPT) code with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member. ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a beneficiary to discuss the beneficiary’s wishes and preferences for medical treatment if he or she were unable to speak or make decisions in the future. You can provide the ACP at the time of the AWV, at the beneficiary’s discretion.

Coding Use the following CPT codes to file claims for ACP as an optional element of an AWV.

ACP CPT Codes and Descriptors
ACP CPT Codes Billing Code 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 a claim for ACP as an optional element of an AWV. Since you are not required to document a specific diagnosis code for ACP as an optional element of an AWV, you may choose any diagnosis code consistent with a beneficiary’s exam.

What are the other Medicare Part B preventive services*

* Alcohol Misuse Screening and Counseling
* Bone Mass Measurements
* Cardiovascular Disease Screening Test
* Colorectal Cancer Screening
* Counseling to Prevent Tobacco Use
* Depression Screening
* Diabetes Screening
* Diabetes Self-Management Training (DSMT)
* Glaucoma Screening
* Hepatitis C Virus (HCV) Screening
* Human Immunodeficiency Virus (HIV) Screening
* Influenza, Pneumococcal, and Hepatitis B Vaccinations and their Administration
* Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD), also known as a CVD risk reduction visit
* IBT for Obesity
* IPPE (also called the “Welcome to Medicare Preventive Visit”)
* Medical Nutrition Therapy (MNT)
* Prostate Cancer Screening
* Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests
* Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
* Screening for Hepatitis B Virus (HBV) Infection
* Screening for Sexually Transmitted Infections (STIs) and 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) Visit the MLN’s Preventive Services Educational Tool for additional resources on Medicare preventive services.

Who is eligible for the AWV?

Medicare covers an AWV for all beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period, and who have not had either an IPPE or an AWV within the past 12 months. Medicare pays for only one first AWV per beneficiary per lifetime and one subsequent AWV per year thereafter.

Is the AWV the same as a beneficiary’s yearly physical?

No. The AWV is not a routine physical checkup that some seniors may get periodically from their physician or other qualified non-physician practitioner. Medicare does not cover routine physical examinations.

Are clinical laboratory tests part of the AWV?

No. The AWV does not include any clinical laboratory tests, but you may make referrals for such tests as part of the AWV, if appropriate.

Do deductible or coinsurance/copayment apply for the AWV?

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

Can I bill an electrocardiogram (EKG) and the AWV on the same date of service?

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

How do I know if a beneficiary already got his/her first AWV from another provider and know whether to bill for a subsequent AWV even though this is the first AWV I provided to this beneficiary*

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). CMS suggests providers check with their Medicare Administrative Contractor (MAC) to see what options are available to verify beneficiary eligibility. Contact your MAC for more information.

PREPARING ELIGIBLE MEDICARE

BENEFICIARIES FOR THE AWV Providers can help eligible Medicare beneficiaries get ready for their AWV by encouraging them to come prepared with the following information:

* Medical records, including immunization records
* Family health history, in as much detail as possible
* A full list of medications and supplements, including calcium and vitamins – how often and how much of each is taken
* A full list of current providers and suppliers involved in Page 14 of 17 providing care