Q: Are there specific requirements for Medicare wellness exams and who can perform them?
A: Medicare offers an initial preventive physical examination (IPPE), which is also known as the “Welcome to Medicare” preventive visit or the annual wellness visit (AWV). Either a physician (a doctor of medicine or osteopathy) or a qualified nonphysician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist) can provide the services.

The IPPE is a one-time initial examination that is covered within the first 12-month period after a participant is enrolled in Part B Medicare only. You would bill Healthcare Common Procedure Coding System (HCPCS) Level II code G0402, “Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment” for the service, which has an average reimbursement of $168.68. However, you can check the Medicare physician fee schedule for your jurisdiction for exact pricing (https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx).

Medicare has not designated a specific International Classification of Diseases Tenth Revision, Clinical Modification (ICD-10 CM) code to use. A couple of options are: Z00.00, “Encounter for general adult medical examination without abnormal findings” and Z00.01, “Encounter for general adult medical examination with abnormal findings,” or another appropriate ICD-10 code based on any findings.

The goals of the IPPE are health promotion, disease prevention, and detection. All services listed in the IPPE must be provided in order to submit the claim for payment. Providers need to perform a physical exam and a review of:

  • Medical and social history
  • Potential risk factors for depression and other mood disorders
  • Functional ability and level of safety

There also needs to be documentation of discussion with the patient regarding:

  • End-of-life planning
  • Results of the findings from the review
  • Any other preventive services the patient might need
    • Screening electrocardiogram (EKG/ECG)
    • Other appropriate screenings and other preventive services

The initial AWV is for those patients who are no longer within the initial 12 months of their Medicare Part B coverage period and have not received an IPPE or AWV within the past 12 months. The HCPCS code to bill for this service is G0438, “Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit,” reimbursed at an average rate of $173.70. A health risk assessment (HRA) must be completed with the visit. The following are just a few elements of the AWV:

  • Administer the HRA
  • Establish list of current providers
  • Establish medical and family history
  • Perform depression screening
  • Perform functional and safety screening
  • Document height, weight, body mass index (BMI), and blood pressure
  • Perform cognitive function assessment
  • Document a screening schedule
  • Document any risk factors
  • Offer appropriate referrals for education and counseling
  • Discuss advance care planning (optional)

This information will need to be reviewed and updated at each subsequent AWV. Use HCPCS code G0439, “Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit,” reimbursed at an average of $117.71 to bill each subsequent visit.

As mentioned, advance care planning (ACP) is an optional element of the AWV that involves a face-to-face conversation with the patient, involving the patient’s wishes and preferences for medical treatment were he or she be unable to speak or make decisions in the future. The discussion is documented in the medical record, and any forms completed are kept in the record, as well. Current procedural code (CPT) code 99497 can be billed for the first 30 minutes of the service, and CPT code 99498 is billed for each additional 30 minutes. These can be billed along with the HCPCS codes for the AWV visit. Average reimbursement for these services are $82.90 and $72.50, respectively.

Medicare waives both the coinsurance and the Medicare Part B deductible once per year for ACP when the following is met:

  • Provided on the same day as the covered AWV
  • Furnished by the same provider as the covered AWV
  • Billed with modifier -33 (preventive service)
  • Billed on the same claim as the AWV

The AWV is not a routine physical exam, and Medicare does not cover routine physical exams.

More details about AWVs and the Welcome to Medicare visit are available on the CMS website (www.cms.gov; go to the Search box at the top of the home page and type in awv to learn more about AWVs or welcome to Medicare for more on the Welcome to Medicare visit).

Get the Most Out of Providing Medicare Wellness Exams
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