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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  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!

  3. Frank Brumley says:

    I just had the Medicare wellness exam. I found it to be an invasion of my privacy. My Doctor which I have regular exams knows what I need from head to toe. All this AWV is a way the government can catalog information about you for their use to interfere in your constitutional rights. You notice this was generated by Obamacare not the people. I will refuse this test from now on. The government has no business in my personal affairs.

  4. Deborah Smith says:

    I have participated in the Medicare annual wellness visit in 2013 and 2014 and I saw it as a waste of my time and an invasion of my privacy.

    I contacted Medicare.gov online and asked them if the annual Medicare wellness visit was mandatory. The Medicare representative had me hold for a few minutes and then came back with an answer; she said that the annual Medicare Wellness visit is not mandatory.

    I then phoned my Medicare HMO and asked a representative if the annual Medicare visit was mandatory or not and I was told it was not mandatory.

    My doctors office phoned me at home to schedule the 2015 annual Medicare wellness visit and I informed them that I had talked to Medicare and my HMO and both told me that the annual Medicare wellness visit is not mandatory so I would not be participating in anymore wellness visits in the future.

    One week later I received a letter from my doctor telling me that if I did not make an appointment for my annual Medicare wellness visit and keep the appointment, that he would be dropping me as a patient due to me not being non-compliant with his instructions. He further said that “your HMO holds me accountable for making sure that you have an annual Medicare wellness visit each year and if you do not call and make an appointment for your wellness visit I will be forced to drop you was a patient.”

    I was forced to make and keep an appointment for this wellness visit that is not considered mandatory. Is there anything I can do about this other than switch to another family doctor. If the annual Medicare wellness visit is not considered mandatory, then patients should have the option to opt-out of the annual Medicare wellness visit. I suspect that this doctor wants the money that Medicare pays him for the annual Medicare wellness visit and that is the only reason he wrote me the letter telling me that he would drop me as a patient if I didn’t participate in the wellness visit.

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