"It's usually covered by your health insurance, it doesn't take much time, and it's a great way to learn about your present and future health." So begins a Harvard Men's Health Watch article on why men need an annual wellness visit (AWV), but the sentiment expressed in the article applies to any Medicare beneficiary. The Medicare AWV is a valuable service for practices to offer their patients. It's valuable from a health and wellness perspective as the AWV can help physicians prevent disease and detect health issues faster. It's also valuable from a financial perspective as the AWV is reimbursed well, with practices receiving around $150 in average reimbursement per patient. This can be increased by performing, when appropriate, the many preventive services that can accompany an AWV. If you want to capture that revenue, you will need to know and understand the billing codes for the Medicare annual wellness visit.
To get started on improving your current process or implementing a new one, download our AWV Toolkit which features five free resources.
This blog will cover coding Medicare annual wellness visit and will also identify and share the codes for the Medicare Part B preventive services more frequently provided as an optional element of an AWV.
How Do I Bill for the Medicare Annual Wellness Visit?
We begin with a discussion of how to bill for the Medicare annual wellness visit. Use the following three HCPCS codes to file claims for AWVs:
- This billing code for the Medicare wellness exam (i.e., AWV) is for the initial annual wellness visit. It includes a personalized prevention plan of service.
- Use this code for all subsequent annual wellness visits. This still includes a personalized prevention plan of service.
- This final of the three billing codes for the Medicare annual wellness visit is not applicable to practices. Rather, it is the code that a federally qualified health center (FQHC) would use for a patient visit that includes an initial preventive physical examination (IPPE) or AWV and includes the typical bundle of services that would be furnished per diem to a Medicare beneficiary receiving an IPPE or AWV.
With the three HCPCS codes for AWVs identified, let's answer a few frequently asked questions about coding and billing for the Medicare annual wellness visit by practices.
Q: Who does Medicare cover under G0438 and G0439?
A: All patients who are not within 12 months after the effective date of their first Medicare Part B coverage period and have not received an IPPE or AWV within the past 12 months.
Q: How often can you bill a Medicare annual wellness visit?
A: Once in a lifetime for G0438 (i.e., the first AWV) and annually for G0439 (i.e., subsequent AWVs).
Q: How much do patients pay for services covered by G0438 and G0439?
A: $0. The copayment/coinsurance is waived, as is the deductible.
Q: Who can perform the Medicare annual wellness visit?
A: For the answer to this surprisingly complicated question, we would suggest reading this blog.
Q: Should practices code the IPPE the same way as the AWV?
A: No. While the IPPE is essentially an AWV and physical combined, it is a unique service. Also known as the “Welcome to Medicare” preventive visit, Medicare pays for a single beneficiary IPPE per lifetime, and the IPPE must be furnished no later than the first 12 months after the beneficiary’s eligibility date for Medicare Part B benefits.
Practices that furnish the IPPE, along with a routine electrocardiogram (ECG), would want to use the following codes:
- Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
- Electrocardiogram, routine ECG with 12 leads; performed as a screening or the initial preventive physical examination with interpretation and report
- Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination
- Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination
Supplementary Medicare Part B Preventive Services
Now that we summarized billing the Medicare wellness visit, let's look at coding some of the more common Medicare Part B preventive services that may be provided to patients at the same time that the AWV is furnished.
Advance Care Planning
Advance care planning is almost always part of the AWV. Such a service should be furnished at the beneficiary's discretion. It is intended to discuss the patient's healthcare wishes if they become unable to make decisions about their care. Part of this discussion typically includes advance directives.
Code advance care planning with the following:
- Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
- Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional; each additional 30 minutes (list separately in addition to code for primary procedure)
Advance care planning is considered a preventive service only when it is provided in conjunction (i.e., on the same day) with an AWV, furnished by the same healthcare practitioner as the covered AWV, reported with modifier -33 (attached to 99497), and billed on the same claim as the AWV. The service can be performed annually.
Another service that typically accompanies an AWV is depression screening. The screening must be delivered with staff-assisted depression care supports in place to best ensure accurate diagnosis, effective treatment, and follow-up. Code it with the following:
- Annual depression screening, 15 minutes
This screening can be performed annually, but it cannot be billed when performed with the initial AWV.
Alcohol Misuse Screening & Counseling
These are two services that are provided regularly, with the misuse screening almost always performed and the counseling performed when potential misuse is identified. All patients are eligible for alcohol screening; patients who are eligible for counseling must screen positive and be competent and alert at the time you deliver the counseling. Code alcohol misuse screening and counseling with the following:
- Annual alcohol misuse screening, 15 minutes
- Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
The screening (G0442) can be performed annually. For those who screen positive, counseling (G0443) can be delivered four times per year.
Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
Also known as a CVD risk reduction visit, this service is essentially cardiovascular risk counseling. Considering heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States, you may not be surprised to learn that this service is often provided with the AWV. Code it as follows:
- Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes
This counseling can be provided annually.
Counseling to Prevent Tobacco Use
If patients use tobacco — regardless of whether they exhibit signs or symptoms of tobacco-related disease — they are eligible to receive tobacco cessation counseling. Code this counseling with the following:
- Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
- Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
Medicare will cover two cessation attempts per year, with each attempt including a maximum of four intermediate or intensive sessions, with the patient receiving up to eight sessions annually.
IBT for Obesity
Patients with a body mass index of 30.0 are eligible for this obesity counseling service. Code it as follows:
- Face-to-face behavioral counseling for obesity, 15 minutes
- Face-to-face behavioral counseling for obesity, group (2–10), 30 minutes
Medicare will reimburse up to 22 visits billed with the codes G0447 and G0473, combined, in a 12-month period. These 12 months are broken down as follows:
- First month: one face-to-face visit week
- Months 2–6: one face-to-face visit every other week
- Months 7–12: one face-to-face visit every month (if the patient meets certain requirements)
At the 6-month visit, healthcare practitioners must perform a reassessment of obesity and determine amount of weight loss. If a patient loses at least 3 kg during the first 6 months, they remain eligible for additional monthly face-to-face visits for months 7–12.
Lung Cancer Screening Counseling and Annual Screening for Lung Cancer With Low Dose Computed Tomography (LDCT)
Medicare will cover this service as long as patients meet all of the following requirements:
- Aged 55 through 77
- No signs or lung cancer symptoms
- Tobacco smoking history of at least 30 pack-years
- Current smoker or one who quit smoking within the last 15 years
- Get a written order for lung cancer screening with LDCT that meets the requirements described in the National Coverage Determinations Manual
Code this service as follows:
- Counseling visit to discuss need for lung cancer screening using LDCT scan (service is for eligibility determination and shared decision making)
- LDCT scan for lung cancer screening
The service can be provided annually for covered patients. In the first year, a healthcare practitioner is required to counsel the patient at a shared-decision-making visit before performing the first lung cancer LDCT screening. In subsequent years, the patient must receive a written order during any appropriate visit.
Prolonged Preventive Services
The final preventive service we’ll discuss is one that is often overlooked by healthcare practitioners but may be of great value for patients. When an approved preventive service requires an extended period of direct-patient contact that goes beyond Medicare’s suggested timeframe, practitioners may add one the following codes:
- Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for the preventive service)
- Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code G0513 for additional 30 minutes of preventive service)
The frequency that you can use these codes will vary based upon the individual preventive service provided to patients.
Successfully Completing the Medicare Annual Wellness Visit
We've reviewed the billing codes for the Medicare annual wellness visit and common preventive services, so you should be in a better position to successfully get paid for these valuable services. But just knowing how to code and bill isn't enough to ensure appropriate reimbursement. You must also understand the steps and documentation Medicare requires. To help you maximize the value of the AWV for your patients and better ensure that you meet these requirements, check out this Medicare AWV checklist.
Disclaimer: CPT codes, descriptions, and other data are copyright 2019 American Medical Association.