When you conduct an online search for information about the Medicare annual wellness visit or AWV, one of the first resources you will find is an independent reference tool called Medicare Interactive. Its description of the AWV is as follows: "The annual wellness visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan." Going by this definition, one might believe that the answer to the question "Who can perform the Medicare annual wellness visit?" is a PCP. End of story, right? Far from it.
In fact, before we can answer this question, we must first take a step back and define two concepts: "perform the AWV" and "provide the AWV."
While "perform the AWV" and "provide the AWV" may appear synonymous, they are not. "Perform" in this context means the ability to do the AWV with the patient under the "direct supervision" of a provider. As we define in our glossary, direct supervision in a medical office setting means "the presence of a physician in the office, although not necessarily in the room, and immediately available for assistance to members of the healthcare team when a service is performed to or on a patient."
"Provide" in this context means an individual is the actual billing provider of the AWV, i.e., the National Provider Identifier (NPI) in the Medicare claim.
With that said, there are many healthcare professionals who can perform the Medicare annual wellness visit or provide the Medicare annual wellness visit — and many who should consider doing so. When completed in an efficient manner, the AWV is not only an important service for Medicare beneficiaries, but it can also be financially worthwhile for organizations.
Let's examine other healthcare professionals — besides PCPs — who can either perform or provide the Medicare annual wellness visit.
We'll begin by discussing those professionals who can provide the AWV as it will help us gain a better understanding of who can perform it. The Centers for Medicare & Medicaid Services (CMS) states that physicians can perform the Medicare annual wellness visit, with a physician in this context defined as a doctor of medicine (MD) or osteopathy (DO). In addition to MDs — which includes the likes of cardiologists and other specialists — and DOs, other healthcare professionals who can provide the AWV are as follows:
MDs and DOs can task their assistants with providing the Medicare AWV. In addressing questions received as part of a national provider call, CMS specifically addressed whether physician assistants (PAs) could provide the AWV or initial preventive physical examination (IPPE) and whether PAs could do so for new or only established patients. Note: IPPE, sometimes referred to as "Welcome to Medicare '' preventive visit, is a review of a Medicare beneficiaries’ medical and social health history, and preventive services education covered once within 12 months of Medicare Part B enrollment.
CMS stated the following: "… a PA may furnish an IPPE or an AWV. Patient status within a physician's office (whether the beneficiary is a new or an established patient) is not specifically addressed in the coverage criteria for the initial IPPE … or the AWV."
Nurse practitioners (NPs) and clinical nurse specialists (i.e., an advanced practice nursing professional who has trained extensively in a specialty practice area) can also provide the AWV (as well as the IPPE). And there's data supporting the value of a nurse-driven AWV program.
An article published in Innovation in Aging shares the results of 12 practices that implemented the AWV as a nurse-run visit. The writers state that by implementing such a model, a practice could "… increase utilization of AWV, increase employee and patient satisfaction, and increase revenue," noting that one of the practices was able to increase its billing by more than 200% and relative value units by nearly 200%.
When one considers the services furnished by urgent care centers, what likely comes to mind is the treatment of a variety of conditions, such as allergic reactions, broken bones, colds and flu, and infections (e.g., eye, ear, sinus). Urgent care centers are also increasingly becoming the go-to source to receive vaccinations and blood tests. We may want to consider adding the Medicare AWVs to that list.
A growing number of urgent care centers are now providing the Medicare AWV. Medicare beneficiaries may find this offering quite appealing. Urgent care centers tend not to require appointments and encourage walk-ins. This means that a Medicare beneficiary essentially dictates when to receive the service versus working around a PCP's schedule and availability. With the number of urgent care centers growing rapidly, there is a high likelihood that there is at least one urgent care center near a beneficiary's home and perhaps one closer than the PCP's office.
While perhaps not a type of healthcare professional per se, we thought it was worth noting that the Medicare annual wellness visit can sometimes be provided via telehealth. Let's go straight to CMS for an explanation of how this could occur.
In September 2019, CMS issued a document of frequently asked questions concerning the telehealth expansion waiver associated with Medicare's Next Generation Accountable Care Organization (ACO) Model. As CMS noted, in traditional fee-for-service Medicare, the use of the telehealth benefit is limited to rural health professional shortage areas (HPSAs), CMS-defined telehealth originating sites, and synchronous telehealth services. This waiver eliminates the rural geographic component of originating site requirements and allows the originating site to include a beneficiary's home, among others. The waiver only applies to beneficiaries aligned to a Next Generation ACO and for services furnished by a Next Generation participant or preferred provider approved to use the waiver.
Concerning the question of, "Can a Medicare annual wellness visit be provided using telehealth in a non-HPSA (i.e., non-rural or urban) area or to a beneficiary in their home?," CMS states, "A provider can use the existing HCPCS codes (G0438 and G0439) to bill the annual wellness visit when the services were provided via telehealth in a non-health professional shortage area (i.e., non-rural or urban) area clinical setting or when the annual wellness visit was provided in the beneficiary's home. In either case, the claim should include the place of service (POS) code 02, which indicates the service was provided using telehealth."
To summarize, the answer to "Who can provide the Medicare annual wellness visit" is any MD, DO, PA, NP or other clinical nurse specialist. Those are the only NPIs that Medicare will accept. Furthermore, whichever NPI bills the service has the responsibility to be the provider training and supervising whatever agent of the provider "performed" the service with the patient.
Now let's discuss what healthcare professionals can perform the Medicare AWV. They are as follows:
There is some debate about the role medical assistants (MAs) can play in performing the Medicare AWV. CMS billing guidelines do not mention these professionals. CMS notes that Medicare Part B covers an AWV if performed by a "qualified non-physician practitioner," which includes physician assistants (as well as nurse practitioners and certified clinical nurse specialists), but not MAs.
So, what is the role of MAs in the Medicare AWV? American Association of Medical Assistants Chief Executive Officer and Legal Counsel Donald A. Balasa attempts to answer that question. He concludes, "It is my legal opinion that federal law permits medical assistants to assist licensed health care providers (e.g., MDs/DOs, nurse practitioners, physician assistants) in the performing of an AWV. However, MAs are not permitted to perform any part of the AWV that requires the medical assistant to make independent clinical judgments or to make clinical assessments or evaluations."
Until CMS addresses the role of medical assistants in the AWV, Balasa's legal opinion may be worth following.
It's true: Pharmacists can perform the Medicare AWV, which we noted in a recent blog. But there are some requirements. Pharmacists can perform an AWV when working under the direct supervision of a physician. In the office setting, direct supervision means "… the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean the physician must be present in the room when the procedure is performed," according to Palmetto GBA, a commercial provider and Medicare administrative contractor.
In fact, pharmacists are well-suited to perform the AWV. An article in the North Carolina Medical Journal that discusses the results of a retrospective chart review on a random sample of 500 patients for 12 months post-AWV concluded that clinical pharmacists who perform AWVs, when supervised by physicians, were associated with "… significantly improved utilization of preventive services."
It is worth pointing out that as the American Society of Health-System Pharmacists notes, pharmacists cannot perform the IPPE.
MAs and pharmacists aren't the only medical professionals who can perform the Medicare annual wellness visit under the direct supervision of a physician. This extends to other types of medical professionals, including health educators, registered dieticians, and nutrition professionals. Furthermore, CMS states that a team of such medical professionals can perform the Medicare annual wellness visit, assuming they do so under direct physician supervision.
Since the AWV can be performed by clinical staff under the supervision of a provider, the broader answer to "who can perform the Medicare annual wellness visit" is anyone a provider has oversight of and trusts. If this categorization sounds very broad, that's because it is — and it's broader than most people understand. The vast majority of practices use MAs or other random "clinical staff" under supervision. That being said, they can even use contracted staff or collaborative partnerships like those with pharmacists.
What is worth noting is that CMS takes no position on the particular tasks that should and should not be performed by specific members of such a team. Rather, CMS states that it believes it is better for the supervising physician to assign tasks to appropriate team members.
CMS goes on to say that, "This approach gives the physician and the team the flexibility needed to address the beneficiary's particular needs on a particular day. It also empowers the physician to determine whether specific medical professionals who will be working on his or her wellness team are needed on a particular day. The physician is able to determine the coordination of various team members during the AWV."
If your organization is thinking about or already furnishing AWVs to Medicare beneficiaries, consider partnering with us at Prevounce. Our AWV platform allows everyone from the MD with 30 years of experience to an MA — and anyone else along a patient's continuum of care who may be providing and performing this service — to complete AWV requirements with consistent quality of care and documentation in a streamlined, cost-effective manner. We help you navigate the required health risk assessment and supply all of the tools required for compliance. These include eligibility checks, automated preventive care schedule creation, and automatic report generation.
We do so in a personalized manner, working with organizations and their providers to assess workflows, determine goals, and jointly identify the solutions that would be most impactful for providers and their patients. And we do so without ever encouraging or supporting specialty providers performing services outside of their scope of practice. Learn what Prevounce can do for you by scheduling your live demo.