Unbiased Analysis of Today's Healthcare Issues

Do I need an Annual Wellness Visit?

Written By: Jason Shafrin - Jun• 14•12

The Affordable Care Act (a.k.a. Health Reform, Obamacare) mandates that Medicare provide an annual wellness visit (AWV) to all beneficiaries free of charge.  Today, I answer some questions related to CMS’s implementation of the mandated annual wellness visit requirement.

What is included in an annual wellness visit?  The AWV includes “the establishment of, or update to, the individual’s medical and family history, measurement of his or her height, weight, body-mass index (BMI) or waist circumference, and blood pressure (BP), with the goal of health promotion and disease detection and fostering the coordination of the screening and preventive services that may already be covered and paid for under Medicare Part B.”  Care coordination is also a key component of the AWV.  The AWV should establish a list of current providers and suppliers that are regularly involved in providing medical care to the individual.  Depression screening, review of the individual’s functional ability, and verifying whether the patient has received preventive care recommendations (as defined by the USPSTF and ACIP).  Additional information on the services provided during an AWV is available here.

Who can provide an annual wellness visit?  Providers eligible to provide an AWV include doctors of medicine or osteopathy, physician assistants, nurse practitioners, or clinical nurse specialists.  Other medical professionals (e.g., health educator, dietitian) can conduct the AWV under supervision of an MD or DO.

 What is a PPPS?  Beneficiaries who see a physician for their AWV receive Personalized Prevention Plan Services (PPPS).  The PPPS are the services the physician is required to provide during the AWV.

How much does an AWV cost patients?  Unlike typical physician visits covered by Medicare Part B, the patient is not responsible for any coinsurance or Part B deductibles.

I am a provider.  How do I bill Medicare for an AMV? There are two HCPCS codes one can use to bill Medicare depending on whether this is the beneficiary’s first wellness visit or not:

  • G0438: Annual wellness visit, including PPPS, first visit
  • G0439: Annual wellness visit, including PPPS, subsequent visit

Are all Medicare beneficiaries eligible for an AWV?  The answer is no.  Newly enrolled beneficiaries are not eligible for a wellness visit; only beneficiaries who have been enrolled in Medicare Part B for at least 12 months are eligible for a wellness visit.  New enrollees, however, are eligible for the new enrollees are instead eligible for the Initial Preventive Physical Exam (IPPE) which is billed under HCPCS G0402.

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2 Comments

  1. […] the ACA, seniors are entitled to an annual wellness exam with no out-of-pocket costs to the patient. Megan Golles highlighted to importance of proper […]

  2. David Wilson says:

    Two additional comments: The AWV is a perfect opportunity to have your healthcare provider review your personal health record since ALL the work is done during the AWV anyway, second, don’t get confused between the IPPE (intro to Medicare) and the AWV. They are similar but different with different billing codes!

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