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:
- 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
- https://www.aafp.org/fpm/topicModules/viewTopicModule.htm?topicModuleId=76