Medicare Wellness Exams | December 2021 | Clinical Corner

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December 1, 2021

MEDICARE WELLNESS EXAMS

Improve Quality and Maximize Revenue

 

The main benefit of the Annual Wellness Visit (AWV) to patients is the creation of a personalized prevention plan, which is a written plan that can help guide their preventive care decisions.  AWVs can boost revenue and provide a template for physicians to help close gaps in many pay-for-performance quality measures. Listed below are important codes that may be billable in addition to the appropriate AWV code (G0402, G0438, G0439) during a visit for a Medicare Wellness Exam.

In 2019, Medicare reimbursed $175 for an AWV per member per year and the AWV was associated with a $38 per member per month ($456 per member per year) decrease in costs, these data suggest that the additional expenditure on primary care can be worth the costs, particularly for a higher-risk population.1

The AWV is a separate service from the Initial Preventive Physical Exam (IPPE). Medicare covers an AWV for all beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period, and who have not had either an IPPE or an AWV within the past 12 months.

 

Important Notes:

1.       Can I bill an electrocardiogram (EKG) and the AWV on the same date of service?

a.       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.

2.       Are clinical laboratory tests part of the AWV?

a.       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.

3.       Is the AWV the same as a beneficiary’s yearly physical?

a.       No. The AWV is not a routine physical checkup that some seniors may get periodically from their physician or other qualified non-physician practitioner. Medicare does not cover routine physical examinations.

4.       When you furnish a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service along with the AWV, Medicare may pay for the additional service. Report the additional Current Procedural Terminology (CPT) code with modifier -25 on the same claim as the AWV.

5.       Advanced Care Planning (ACP) is the face-to-face conversation between a physician (or other qualified health care professional) and a beneficiary to discuss the beneficiary’s wishes and preferences for medical treatment if he or she were unable to speak or make decisions in the future. You can provide the ACP at the time of the AWV, at the beneficiary’s discretion, billed with modifier -33 on the same claim as the AWV.

References:

  1. Adam L. Beckman, BS, Adan Z. Becerra, PhD , Anna Marcus, BS , C. Annette DuBard, MD, MPH , Kimberly Lynch, MPH , Emily Maxson, MD , Farzad Mostashari, MD, ScM , Jennifer King, PhD. Medicare Annual Wellness Visit Association with Healthcare Quality and Costs. The American Journal of Managed Care, March 2019, Volume 25, Issue 3
  2. https://www.aafp.org/fpm/topicModules/viewTopicModule.htm?topicModuleId=76