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Annual Wellness Exam/Annual Wellness Visit (AWV) (Q&As)

Pursuant to section 4103 of the Affordable Care Act of 2010 (ACA), the Centers for Medicare & Medicaid Services expanded coverage to allow for an Annual Wellness Visit (AWV) including personalized prevention plan services (PPPS) for an individual who is no longer within 12 months of the effective date of his/her first Medicare Part B coverage period, and has not received either an initial preventive physical examination (IPPE) or an AWV with the past 12 months. Medicare coinsurance and Part B deductibles do not apply.

Our Provider Contact Center has received multiple questions concerning the appropriate billing of this service. Here are some of those questions and answers.

Question:
Why did Medicare establish the AWV?
Answer:
Pursuant to section 4103 of the Affordable Care Act of 2010 (ACA), the Centers for Medicare & Medicaid Services (CMS)expanded coverage to allow for an Annual Wellness Visit (AWV) including personalized prevention plan services (PPPS) for an individual who is no longer within 12 months of the effective date of his/her first Medicare Part B coverage period, and has not received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months. Medicare coinsurance and Part B deductibles do not apply.


Question:
What is the Annual Wellness Visit (AWV)?
Answer:
It is a new benefit to Medicare beneficiaries as enacted by the Affordable Care Act (ACA) of 2010.


Question:
Where can I find more information on this new benefit?
Answer:
The CMS has published Medicare Learning Network (MLN) Matters MM7079 based on updates to the Internet Only Manual (IOM). CMS is also updating two different IOM publications, Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 280.5, and Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1.1 and Chapter 18, Section 140.


Question:
What are the appropriate procedure codes for the AWV?
Answer:
CMS has created two new codes:
G0438 - Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit
G0439 - Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit


Question:
The patient wants the AWV before it has been 12 months since the previous AWV or Initial Preventive Physical Examination (IPPE). Must I provide the patient with an Advance Beneficiary Notice of Noncoverage (ABN)?
Answer:
The timing of these services is a statutory benefit and therefore services outside the payable periods do not require an ABN.


Question:
Is the patient responsible for payment of deductible and coinsurance when they receive the AWV?
Answer:
Medicare does not apply deductible and coinsurance for an AWV. The patient would have no responsibility, unless receiving another service at the same time. Providers may need to explain this to the patient.


Question:
Is procedure code G0438, a once in a lifetime benefit?
Answer:
Yes, the G0438 is the initial AWV for that patient. Bill any subsequent services using the G0439.


Question:
This is the first AWV I've provided to the patient. The patient has had one previously from their former doctor. Do I use procedure code G0438 or G0439?
Answer:
The correct code is G0439. The determination of whether the AWV is an initial or subsequent is based on the patient and not the person providing the service.


Question:
The guidelines on the AWV show that Medicare will allow the service once per year. Is this a 365-day year or 12 calendar months?
Answer:
Medicare would look to verify that at least 11 full calendar months have passed since the last AWV.


Question:
The beneficiary just became eligible for Medicare. Will Medicare pay for an AWV?
Answer:
During the first year of Medicare enrollment, the patient is not eligible for the AWV. Medicare can allow the IPPE (Welcome to Medicare visit) during this time. The AWV could be payable by Medicare after the first year of enrollment and only if it has been more than 11 full months following the IPPE (if the patient received the IPPE).


Question:
Our medical record documentation does not support the requirements for the AWV as listed in the CMS IOM. Do we bill using Modifier 52?
Answer:
No, Modifier 52 is not appropriate. Providers should only submit the procedure code that best reflects the services they provided. If the documentation does not support the AWV procedures, choose another preventive service procedure code.


Question:
Where can I find a description of the services needed for an AWV?
Answer:
CMS has published a Medicare Learning Network (MLN) Matters article MM7079 that contains the required services.


Question:
Is there a specific diagnosis code required when billing for the AWV either initial or subsequent?
Answer:
Medicare does not have a specific required diagnosis code. Providers would use a preventive diagnosis code.


Question:
Is there a problem if I provide a screening breast and pelvic exam on the same date as the AWV?
Answer:
No. Medicare can allow both services. Please see the information in the CMS IOM, Publication 100-04, Chapter 12, Section 30.6.1.1 and 30.6.2 to determine specific billing instructions


Question:
My physician has additional service he would like to perform at the same time as the AWV. This would include the zostavax injection, a tetanus immunization, chest x-ray, EKG, and certain blood tests. Are these things payable separately? Is a modifier required?
Answer:
Each of the additional items has its own rules and regulations within Medicare. These services are not part of the AWV. If performed, the documentation must show the medical necessity for the service. Providers can find more information on the coverage of these items by going to the WPS Medicare Part B website and performing a search under the service. Providers may also access the Centers for Medicare & Medicaid Services (CMS) website for more information. No modifier is required.


Question:
The patient is in the first year of their Medicare eligibility. I have performed a "Welcome to Medicare" visit. Next year when I provide the AWV is it an initial or subsequent?
Answer:
The first AWV received by the patient is the initial. The provision of the "Welcome to Medicare" visit does not preclude billing the initial AWV.


Question:
The patient scheduled the encounter for an AWV. However, once in the office, they also brought up several medical conditions. Can I bill for the AWV in addition to the medically necessary Evaluation and Management (E/M) procedure code?
Answer:
You can bill for both services when the E/M service is significant and separately identifiable from the AWV. Providers should report modifier 25 when appropriate. Some of the components of a medically necessary E/M service may have been part of the AWV and should not be included when determining the most appropriate E/M procedure code. Please see the information in the CMS IOM Publication 100-04, Chapter 12, Section 30.6.1.1 and 30.6.2 to determine specific billing instructions.


Question:
What does the Remittance Notice state when denying the visit if one year has not elapsed between the Initial Preventive Physical Exam (IPPE) and the AWV?
Answer:
CWF (Common Working File) will count 11 full months starting with the month a paid IPPE is in the beneficiary's history file.
  • Remittance Reason Code 119: Benefit maximum for this time period or occurrence has been reached.
  • Remittance Remarks Code N130: Consult plan benefit documents/guidelines for information about restrictions for this service.
  • Group Code: PR (Patient Responsibility)


Question:
What does the Remittance codes states when billing G0438 or G0439 in the first year of eligibility?
Answer:
Contractors shall line-item deny claims for an AWV, G0438 or G0439, rendered within the first 12 months after the effective date of a beneficiary's first Medicare Part B coverage using the following messages.
  • Remittance Reason Code 26: Expenses incurred prior to coverage.
  • Remittance Remarks Code N130: Consult plan benefit documents/guidelines for information about restrictions for this service.
  • Group Code: PR (Patient Responsibility)


Question:
What does the Remittance Notice codes state when G0438 is already paid?
Answer:
Contractors shall line-item deny claims for An AWV, G0438 using the following messages:
  • Remittance Reason Code 149: Lifetime benefit maximum has been reached for this service/benefit category.
  • Remittance Remarks Code N117: This service is paid only once in a patient's lifetime.
  • Group code: PR (Patient Responsibility)


Question:
Can a registered nurse record the data for the AWV?
Answer:
Yes. CR 7079 states an RN can record the data.


Question:
Can a Registered Nurse perform this service?
Answer:
Yes, as long as they are a licensed professional and their state license allows them to perform the services. The MD/DO or a non-physician practitioner must provide direct supervision of the service when billing under a Medicare provider number. The billing is under the entity providing the direct supervision.


Question:
I know that an RN can perform this service under the direct supervision of an MD/DO. Can the RN perform this for a new patient?
Answer:
Yes.


Question:
Can a nurse midwife perform the AWV?
Answer:
The information contained in the CR defines a health professional as a doctor, non-physician practitioner or a medical professional or a team of medical professionals working under the supervision of a physician. The determination would be as to whether his/her state license would allow the performance of the services required for the AWV.


Question:
The patient thinks they may have already received the AWV. If I bill a subsequent AWV (G0439) with there being no initial AWV (G0438) in history, will my claim deny?
Answer:
Medicare would not deny this service.


Question:
What is included in the AWV?
Answer:
The specific requirements are located in the MM7079.


Question:
I am a teaching physician, may I bill for the AWV when provided by a resident?
Answer:
Teaching physicians may submit claims for services furnished by residents in the absence of a teaching physician when the situations meets all of the requirements as described in the CMS IOM, Publication 100-04, Chapter 12, Section 100.1.1C are met. HCPCS codes G0438 and G0439 are included in this policy as of January 1, 2011. Please see the Medicare Learning Network Matters Article MM7079 for more information.


Question:
Is a physician legally required to perform this service or can they simply continue to perform the yearly physical exam.
Answer:
Medicare does not require a physician to perform this service. However, a physician may look to perform this service in conjunction with the annual exam. Any duplicative services would be included in the annual wellness exam and reduced from the annual physical exam.


Question:
We are providing both a yearly physical exam and the AWV on the same date. How do will bill for these services?
Answer:
In choosing the pricing for the yearly physical exam, you must remove any elements that are included in the AWV. The provider would submit the AWV in full with reduced pricing on the yearly physical exam. This would reduce the patient's liability. Please see the information in the CMS IOM, Publication 100-04, Chapter 12, Sections 30.6.1.1 and 30.6.2 to determine specific billing instructions.


Question:
Can a physician bill Medicare for a separate evaluation and management (E/M) service on the same date as the AWV?
Answer:
When billing for an E/M and the AWV on the same day, the provider must remove those portions of the E/M that are included in the AWV. You cannot include any duplicative services in the coding of the E/M. Once that process is complete, you would then look to see if the E/M met the Modifier 25 guidelines - significant, separately identifiable. If the E/M is a great amount of additional work over and above what would be performed in the AWV, then you may append modifier 25 to the E/M procedure code. If it is not, then bill the AWV only. Please see the information in the CMS IOM, Publication 100-04, Chapter 12, Sections 30.6.1.1 and 30.6.2.


Question:
When a resident provides services under the primary care exception do we use the low-level evaluation and management (E/M) service codes or the annual wellness visit codes?
Answer:
A provider should always bill the procedure code that accurately reflects the service provided. In the situation described, use the AWV procedure codes. These are part of the primary care exception.


Question:
We provided an injection on the same day as the AWV. Does this situation require the 25 modifier?
Answer:
This does not currently require a 25 modifier. Please continue to watch the National Correct Coding Initiative edits for any updates.


Question:
Does the AWV replace all of the preventive exam procedure codes?
Answer:
No.


Question:
How does a provider assess the patient's functional abilities?
Answer:
This can be direct observation of the patient, the use of appropriate screening questions or a screening questionnaire. If using a screening questionnaire, then a national professional medical organization must recognize this form.


Question:
Is the patient's height and weight required in the medical record documentation or can a provider document the waist circumference?
Answer:
The published information indicates the AWV includes the measurement of an individual's height, weight, BMI, (or waist circumference, if appropriate.)


Question:
Is the information on the provision of the "written screening schedule, such a checklist for the next 5 to 10 years, as appropriate" required as a separate document or can it be part of the record?
Answer:
It can be part of the record, and the provider can supply a copy to the patient.


Question:
Is additional testing included in the AWV?
Answer:
No


Question:
Is there a way for a provider to verify the date of an initial or subsequent AWV?
Answer:
The Centers for Medicare & Medicaid Services (CMS) Secure Net Access Portal (C-SNAP) displays this information.


Question:
Depression screening requires some type of nationally recognized testing tool to assess the potential for depression. Does the form have to be separate from the record or can we build this into the electronic medical record?
Answer:
A provider may build the testing tool into the electronic medical record, but the documentation should show the source of the tool should Medicare request medical record documentation.


Question:
The patient's primary insurance does not recognize the G0438 or G0349 procedure codes. How do we submit these charges to Medicare?
Answer:
Submit the AWV codes to the primary insurance and then submit the charges to Medicare for secondary payment.


Question:
Are specific national recognized tests required for functional and cognitive ability?
Answer:
The assessment of these areas can be by direct observation.


Question:
My patient is mentally retarded or suffering from senile dementia. Can I include a sentence to this effect and would this exclude me from documenting certain aspects of the AWV?
Answer:
Many of the services that are part of the AWV include assessment of patient abilities. Providers will document responses, if any, received from these patients as any others.


Question:
The instructions state the review of the patient's potential risk for depression should be determined based on use of an appropriate screening instrument. How do we document this when the patient is mentally deficient or has dementia?
Answer:
The provider would document the patient's response or lack thereof based on the screening instrument chosen.


Question:
Are there requirements on the tools to use in accessing cognitive abilities? Is the "mini-cog" a valid tool?
Answer:
The assessment of an individual's cognitive impairment may be by direct observation or through information gathered from others. (See CR 7079 for more complete information.) Medicare does not endorse any particular tool.


Question:
Does Medicare recognize Modifier 33?
Answer:
No. Medicare does not recognize this modifier.
Question:
How do I bill Medicare for an AWV if the patient has a primary insurance?
Answer:
A provider should always submit the procedure code reflecting the service provided. Bill the primary insurance using the procedure code for the AWV and receive the information (payment or rejection), then bill Medicare. Medicare will process based on the Medicare rules evaluating the payment from the primary insurance. However, if the primary denies because they do not recognize the procedure code, Medicare can make payment.

Page Last Updated: Wednesday, 26-Nov-2014 12:30:31 CST