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Annual Wellness Visit (AWV)

If you’ve had Medicare Part B (Medical Insurance) for longer than 12 months, you can get a yearly “Wellness” visit to develop or update a personalized prevention plan based on your current health and risk factors. This includes:

  • Health risk assessment (your doctor or health professional will ask you to answer some questions before or during your visit, which is called a health risk assessment. your responses to the questions will help you and your health professional get the most from your yearly “wellness” visit.)
  • Review of medical and family history.
  • Develop or update a list of current providers and prescriptions.
  • Height, weight, blood pressure, and other routine measurements.
  • Detection of any cognitive impairment.
  • Personalized health advice.
  • A list of risk factors and treatment options for you.
  • A screening schedule (like a checklist) for appropriate preventive services.

HCPCS/CPT Codes


G0438 – Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit

G0439 – Annual wellness visit, includes a personalized prevention plan of service (PPPS), 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

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)

ICD-10-CM (ICD-9-CM) Codes


No specific diagnosis code

Contact local Medicare Administrative Contractor (MAC) for guidance

Who Is Covered


All Medicare beneficiaries:

  • Who are not within 12 months after the effective date of their first Medicare Part B coverage period; and
  • Who have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months

Frequency


  • Once in a lifetime for G0438 (first AWV); or
  • Annually for G0439 (subsequent AWV) and G0468 (AWV in FQHC)
  • Annually for optional 99497, 99498

Beneficiary Pays


G0438 and G0439:

  • Copayment/coinsurance waived
  • Deductible waived

G0468:

  • Copayment/coinsurance and deductible waived for Advance Care Planning when furnished as an optional element of an AWV
  • AWV or IPPE must be provided with a standard bundle of services available to all beneficiaries; for more information about billing for this service, refer to Medicare Claims Processing Manual, Chapter 9, Section 60.2

99497 and 99498:

  • Copayment/coinsurance waived
  • Deductible waived

Frequently Asked Questions (FAQs)


Can a Home Health provider conduct an AWV in the patient's home?

No, a Home Health Agency cannot provide the AWV. This service is not billable on institutional types of bill 32x or 34x.

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 every year or so 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.

Who can perform the Annual Wellness Visit (AWV)?

Medicare Part B covers the Annual Wellness Visit (AWV) if it is furnished by a:

  • Physician (doctor of medicine or osteopathy)
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Medical professional (including a health educator, a registered dietitian, nutrition professional, or other licensed practitioner) or a team of such medical professionals working under the direct supervision of a physician (doctor of medicine or osteopathy)

As discussed in the preamble of the calendar year 2011 Physician Fee Schedule rule, CMS is not assigning particular tasks or restrictions for specific members of the team. We believe it is better for the supervising physician to assign specific tasks to qualified team members (as long as they are licensed in the State and working within their state scope of practice). This approach gives the physician and the team the flexibility needed to address the beneficiary’s particular needs on a particular day. It also empowers the physician to determine whether specific medical professionals who will be working on his or her wellness team are needed on a particular day. The physician is able to determine the coordination of various team members during the AWV.

Other Notes


  • For services furnished on or after January 1, 2016, Advance Care Planning is treated as an optional preventive service when furnished with an AWV.
    • Practitioners may provide Advance Care Planning outside of the AWV multiple times in a year, but the practitioner must document a change in the beneficiary’s health for each additional service in a year. When providing Advance Care Planning outside the AWV, the beneficiary is responsible for the deductible and coinsurance.
  • The deductible and coinsurance for Advance Care Planning is only waived when furnished as an optional element of an AWV, which requires:
    • Billing with modifier –33 (Preventive Service) on the same claim as an AWV
    • Furnishing on the same day and by the same provider as the AWV

References



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