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CMS New Annual Wellness Visit Benefit Explained
By Amy Wright, CPC-H, CCP-H, CPC, CCP, CMBS

On January 1, 2011, new HCPCS codes G0438 and G0439 were introduced regarding annual wellness visits (AWVs). This improvement in Medicare coverage for preventive services, made possible through the Patient Protection and Affordable Care Act, has the potential to yield some significant revenue to primary care practitioners.

In many coders’ reference forums, several questions have been asked by those wondering what an AWV is and its purpose. An AWV is a preventive physical exam, which includes personal prevention plan services (PPPS). It will include the establishment of (or update to) an individual's medical and family history and measurement of his or her height, weight, body mass index or waist circumference, and blood pressure with the goal of health promotion and disease detection. The hope is that the AWV will serve to coordinate other screening and preventive services covered and paid for under Medicare Part B.

G0438 and G0439 are based on the AWV being a first or subsequent service for the patient, not a first visit or subsequent visit to the same practitioner. In the event that a beneficiary selects a new health professional to complete a subsequent AWV, the new health professional will bill the encounter with G0439 even though the health professional didn't perform the first AWV. All subsequent AWVs should be billed with G0439.

The initial preventive physical exam (IPPE), sometimes called the “Welcome to Medicare” physical, is still reported with code G0402. It remains a separate benefit from the AWV. The difference between the IPPE and the first AWV is that the IPPE is eligible for coverage only during the beneficiary's first 12 months of Medicare Part B entitlement, while AWV claims are not payable until after the first 12 months of a beneficiary's entitlement. If a patient did not have an IPPE within the period when he or she was eligible for it, this does not prohibit the patient from receiving an AWV once eligible.

Coders sometimes ask how often they can report G0438. It is once per lifetime per beneficiary. However, there is no limit to the number of subsequent AWVs (G0439) that can be reimbursed, but they cannot be paid until 12 months after a previous AWV. Medicare deductible and coinsurance for AWVs is waived.

Coders also ask whether a medically necessary evaluation and management (E/M) service can be reported at the same time as an AWV or an IPPE. The answer is yes. When the practitioner provides a medically necessary E/M service that is significant, and separately identifiable in addition to the IPPE or an AWV, CPT codes 99201 to 99215 may be reported depending on the clinical circumstances of the case. Modifier 25 should be reported with the medically necessary E/M service identifying it as being significant, separately identifiable from the IPPE or AWV.

More information about the AWV can be found in The Medicare Benefit Policy Manual, Chapter 15, §280.5, which provides helpful definitions regarding the required elements of an AWV.

— Amy Wright, CPC-H, CCP-H, CPC, CCP, CMBS, acts as a coding and compliance consultant with Kraft Healthcare Consulting, LLC an affiliate of Kraft CPAs PLLC.