Cpt For Medicare Wellness Exam

Medicares Annual Wellness Visit

The Medicare Annual Wellness Visit is a yearly appointment with a health professional to identify health risks and help reduce them and to create or update a personalized prevention plan. During a Medicare AWV, health professionals should also review any current opioid prescriptions, detect any cognitive impairment, and establish or update medical and family history.

Preparing Eligible Medicare Patients For The Awv

Providers can help eligible Medicare patients prepare for their AWV by encouraging them to bring the following information:

• Medical records, including immunization records
• A detailed family health history
• A full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
• A full list of current providers and suppliers involved in their care, including community-based providers and behavioral health specialists

What Is The Cpt Code For Medicare Wellness Exam

· should be referred to their assigned PCP if a more comprehensive preventive service is warranted. Medicare HMO annual visit CPT code G0402, G0438 and G0439 coverage Medicare Advantage Program Coding for Welcome to Medicare and Annual Wellness Visits

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Closing Quality Measure Gaps

Many pay-for-performance measures can be addressed during Medicare wellness visits, including these, which are associated with the following programs: Core Quality Measures Collaborative , the Integrated Healthcare Associations California Value Based P4P Program , and the National Committee for Quality Assurances Healthcare Effectiveness Data and Information Set . Measures used by the Medicare Shared Savings Program 2018 and 2019 reporting years are also listed.

Talk To Your Medicare Patients About Awv

Better patient care starts with preventive wellness visits. Download the AAFPs patient flier and use it to talk with your Medicare patients about the importance of scheduling a free, personalized prevention visit with you.

Read more about AWVs in the Making Sense of MACRA: Annual Wellness Visit supplement »

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Coding And Billing A Medicare Awv

G0438: Annual wellness visit, includes a personalized prevention plan of service , initial visit

G0439: Annual wellness visit, includes a personalized prevention plan of service , subsequent visit

G0468: Federally qualified health center visit, IPPE, or AWV a FQHC visit that includes an initial preventive physical examination or annual wellness visit and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving IPPE or AWV

Diagnosis code V70.0 Initial Annual Wellness Visit G0438 Subsequent Annual Wellness Visit G0439

Medicare will pay a physician for an AWV service and a medically necessary service, e.g. a mid-level established office visit, Current Procedural Terminology code 99213, furnished during a single beneficiary encounter. It is important that the elements of the AWV not be replicated in the medically necessary service. Physicians must append modifier -25 to the medically necessary E/M service, e.g. 99213-25, to be paid for both services.

For example, for the patient who comes in for his Annual Wellness Visit and complains of tendonitis would be billed as follows: CPT ICD9, G0438 V70.0, 99212-25 726.90

Preparing Eligible Patients For The Annual Wellness Visit

Providers can help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment:

• Medical records, including immunization records
• Detailed family health history
• Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
• Full list of current providers and suppliers involved in their care, including community-based providers , and behavioral health specialists

Part B covers an AWV if performed by a:

• Qualified non-physician practitioner
• Medical professional , or a team of medical professionals that a physician directly supervises

When you provide an AWV and a significant, separately identifiable, medically necessary Evaluation and Management service, we may pay for the additional service. Report the additional CPT code with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patients illness or injury or to improve the functioning of a malformed body part.

You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV and G0439 is for subsequent AWVs. Remember, you must not bill G0438 or G0439 within 12 months of a previous G0402 billing for the same patient. We deny these claims with messages of, Benefit maximum for this time period or occurrence has been reached and Consult plan benefit documents/guidelines for information about restrictions for this service.

Coding

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They replaced deleted code 99420. According to the PPACA, a Health Risk Assessment : must identify chronic diseases, injury risks, modifiable risk factors, and urgent health needs of the individual. may be furnished through an interactive telephonic or web-based program. may be offered during the encounter with a health care professional.

CPT Codes 99201 – 99205 Established Patient CPT Codes 99211 – 99215 Initial Wellness Visit Medicare – Initial HCPCS Code G0438 – Subsequent HCPCS Code G0439.

G0438. This billing code for the Medicare wellness exam is for the initial annual wellness visit. It includes a personalized prevention plan of service. G0439. Use this code for all subsequent annual wellness visits. This still includes a personalized prevention plan of service. G0468.

If this visit is done through A/V telehealth, then CPT code 99412 has Modifier 95 appended. For example: CPT codes for audio-only (99441- … *Checking in on members, completing an Annual /Preventive Wellness Visits through telehealth appointments,.

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Awv For Federally Qualified Health Clinics And Advanced Care Planning

As shown above, CPT code G0468 allows federally qualified health clinics to bill for AWVs. This code covers all three varieties of AWVs at the same reimbursement rate.

That said, you would still provide the type of AWV most appropriate based on your patients eligibility window.

Advanced care planning is not a type of AWV, but it can play a part in the program.

ACP is a formal process to understand your patients preferences for future medical care. It is an opportunity to make a plan. And an AWV can be a chance to create it. Often, providers will complete ACP during an AWV.

ACP is fully covered for patients under Medicare Part B, so long as it is conducted during the AWV. And it is reimbursable for your practice. It can be billed in concurrence with an AWV using CPT code 99497.

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What Is The Medicare Annual Wellness Visit

The Annual Wellness Visit allows practices to gain information about the patient, including medical and family history, health risks, and specific vitals. Not to be confused with a complete physical examination, the purpose of the AWV is to review the patients wellness and develop a personalized prevention plan. The services provided during the AWV are different from a typical preventive care visit and expand to include emotional and psychological well-being, in addition to the patients physical well-being. The AWV provides an opportunity for physicians to improve the quality of care, assist in patient engagement, and optimize payment opportunities.

How Do I Identify Patients Who Would Benefit From Awvs

There are many different strategies that a practice may choose to use when identifying patients that are eligible for IPPE or AWV. Some practices may inform patients that they are eligible for an AWV during a regular office visit. Practices wanting to achieve higher rates of AWV among eligible patients use EHR data to identify patients that qualify for IPPE or AWV.

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How Should I Schedule Staff To Provide Awvs

Each practice must determine the most efficient way to schedule IPPEs/AWVs. Due to the length of the IPPE/AWV, some practices designate specific time slots during the week or specific days for these types of visits. Some practices have chosen to have one eligible medical professional complete all visits, such as a care coordinator, rather than the patients primary care providers. Practices that have hired care coordinators may utilize these licensed professionals to complete most or all of the AWV. Determining the most efficient schedule for staff may require some trial and error before the best approach is found.

Incorrect Coding Equals Lost Revenue

The mistake he was making that was costing him money is the same mistake I saw recently in a large primary care group. It was billing a subsequent annual wellness visit when the patient was eligible for an initial annual wellness visit.

The physician, like the group I visited recently, billed the Welcome to Medicare visit in the first year the patient was enrolled in Medicare and then billed a subsequent wellness visit the next year. They missed the initial annual wellness visit.

The correct sequence is:

• First, bill the Welcome to Medicare visit. The patient is eligible for this service within the first year of enrollment with Medicare.
• Second, bill the initial annual wellness visit. The patient is eligible for this after 11 full months have passed since the Welcome to Medicare visit, or if they didnt have the Welcome to Medicare visit in the first full year of enrollment.
• Third, bill the subsequent annual wellness visit .

Why does it make such a big difference?

The payment for the initial annual wellness visit is much higher than the payment for the subsequent wellness visit.

Run a CPT® frequency report

My first suspicion that the group was billing these incorrectly was when I looked at the volume for these three visits. There werent many initial annual wellness visits.

If you are wondering if the primary care clinicians in your group and the coders understand this, run a frequency report that shows the number of times these three codes were billed.

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What Is An Annual Wellness Visit

The Centers for Medicare & Medicaid Services established the Annual Wellness Visit to keep Medicare beneficiaries healthy and promote preventive care. AWVs are provided with no patient cost sharing.

An AWV is available after a Medicare beneficiary has had Part B for longer than 12 months. The first AWV is available to beneficiaries who have not received an Initial Preventive Physical Examination or AWV in the previous 12 months. Subsequent AWVs are covered once every 12 months. At a minimum, AWVs include:

An AWV can be provided by a physician , qualified non-physician practitioner , medical professional , or team of medical professionals who are directly supervised by a physician.

Streamline Awvs With Care Coordination Software

Knowing the CPT codes for AWVs can help your practice project revenue and optimize your care teams capacity. But to deliver and document wellness visits, youll want a system in place to manage your program.

A practical resource, such as care coordination software, will keep key details from being lost or overlooked. This will promote efficiency for you and your staff and help patients succeed. Care coordination software can streamline the creation of patient care plans, support staff workflows, and simplify billing. ThoroughCares software solution offers these exact features.

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Approaches To Help Your Practice Get Started

• AWV can be provided to all Medicare Part B patients.
• Use this service to identify patients who would benefit from a discussion regarding their self-management goals.
• Choose patients the staff has identified as highest risk .
• Use this service to risk stratify your patient population.
• Use this service to document diagnoses and conditions to accurately reflect patient severity of illness and risk of high-cost care.

There’s More To Medicare’s Annual Wellness Visit

Clinicians and office staff can benefit from a refresher course about how to code claims correctly for prompt payment.

With coding and payment policy regarding the Annual Wellness Visit constantly changing and updating, office staff and clinicians can benefit from a refresher course about how to code claims correctly for prompt payment.

The AWV is a face-to-face preventive visit for beneficiaries, not a head-to-toe physical examination. The AWV includes a personalized prevention plan of service. Section 4103 of the Affordable Care Act specifically intended this visit to furnish personalized health advice, referrals as appropriate for health education, and preventive counseling services or programs aimed at reducing identified risk factors, as well as to promote self-management and wellness.

However, there is much more to the AWV. In the past, Medicare beneficiaries often did not receive the preventive and wellness services they needed to stay healthy, to avoid or delay the onset of disease, and to lead productive lives. This was due, at least in part, to cost-sharing requirements that were barriers to access. The AWV aims to help alleviate such barriers.

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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:

G0438

• This billing code for the Medicare wellness exam is for the initial annual wellness visit. It includes a personalized prevention plan of service.

G0439

• Use this code for all subsequent annual wellness visits. This still includes a personalized prevention plan of service.

G0468

• 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 would use for a patient visit that includes an initial preventive physical examination 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 and annually for G0439 .

Q: How much do patients pay for services covered by G0438 and G0439?

A: $0. The copayment/coinsurance is waived, as is the deductible.

G0402

G0403

G0404

Annual Wellness Visit Health Risk Assessment

The AWV includes a HRA. See summary below of the minimum elements in the HRA. Get more information in the CDCs A Framework for Patient-Centered Health Risk Assessments booklet, including:

• Evidence suggests HRA use and follow-up interventions can positively influence health behaviors
• Definition of the HRA framework and rationale for its use
• Guidance on HRA use, reduction of health disparities, and improving health outcomes through identifying modifiable health risks and providing behavior change interventions

Perform Health Risk Assessment

• Get patient self-reported information
• You or the patient complete the HRA before or during the AWV it shouldnt take more than 20 minutes

1.Establish patients medical and family history

At a minimum, document:

2.Establish list of current providers and suppliers

3. Measure

12. Screen for potential Substance Use Disorders

1. Review and update Health Risk Assessment

4.Measure

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How Can I Educate Patients About Awvs And What To Expect

Educating patients prior to the visit is important for achieving patient satisfaction. Patients should be aware that the AWV is focused on prevention and is not an annual physical exam. While the AWV is covered without cost sharing by Medicare, the patient should understand that if they discuss a medical problem during the AWV they will be billed for the Evaluation and Management visit and any applicable cost sharing will apply. Some practices have reported that patients sometimes present with a condition or situation at the time of their AWV. Those practices have mitigated this issue by addressing the patients immediate issue at that time to provide the visit with no cost sharing.

Practices can use many modes to reach patients about the benefits of the AWV. Outreach can be provided in person , by mailed letter, by secure electronic messaging in a patient portal, through phone calls, or various other methods. For example, a practice may send a happy birthday postcard to patients reminding them to schedule their AWV.

Get The Most Out Of Providing Medicare Wellness Exams

Q: Are there specific requirements for Medicare wellness exams and who can perform them?A: Medicare offers an initial preventive physical examination , which is also known as the Welcome to Medicare preventive visit or the annual wellness visit . Either a physician or a qualified nonphysician practitioner can provide the services.

The IPPE is a one-time initial examination that is covered within the first 12-month period after a participant is enrolled in Part B Medicare only. You would bill Healthcare Common Procedure Coding System Level II code G0402, Initial preventive physical examination face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment for the service, which has an average reimbursement of $168.68. However, you can check the Medicare physician fee schedule for your jurisdiction for exact pricing .

Medicare has not designated a specific International Classification of Diseases Tenth Revision, Clinical Modification code to use. A couple of options are: Z00.00, Encounter for general adult medical examination without abnormal findings and Z00.01, Encounter for general adult medical examination with abnormal findings, or another appropriate ICD-10 code based on any findings.

The goals of the IPPE are health promotion, disease prevention, and detection. All services listed in the IPPE must be provided in order to submit the claim for payment. Providers need to perform a physical exam and a review of:

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