Annual Wellness Visits

What is an Annual Wellness Visit (AWV)?

The Centers for Medicare & Medicaid Services established the Annual Wellness Visit (AWV) to keep Traditional Medicare patients healthy and promote preventive care. AWVs are conducted yearly with a health professional to identify and reduce health risks and create or update a patient’s personalized prevention plan. AWVs are provided with no patient cost sharing.

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

Advance Care Planning can be provided with an AWV, at the patient’s discretion. This involves a face-to-face conversation between a physician (or other qualified healthcare professional) and the patient to discuss the patient’s wishes and preferences for medical treatment if he or she were unable to speak or make medical decisions in the future.

An AWV can be provided by a physician (MD or DO), qualified non-physician practitioner (nurse practitioner, physician assistant, or certified clinical nurse specialist), or medical professional or team of professionals (health educator, registered dietitian, nutrition professional, or other licensed practitioner, such as a medical assistant) who are directly supervised by a physician.

Why provide AWVs to your patients?

AWVs are beneficial for patients and providers, even without a physical exam. Patients receive a comprehensive health assessment and personalized prevention plan. AWVs also help providers serve patients and keep them healthy. During the AWV, the provider assesses the patient and ensures the patient is receiving the right medication, screens for potential problems such as depression, and provides the patient with a prevention plan.

The AWV is a revenue stream for providers and can also support your practice in value-based care. The components of the AWV meet quality metrics that fulfill Quality Payment Program requirements. For organizations participating in the Medicare Shared Savings Program or other alternative payment models, AWVs can be a tool for patient attribution and advancing quality improvement initiatives (for example, preventive screenings). Additionally, your practice can use the information gathered during the AWV throughout the year to support the care and treatment of the patient. As a part of the AWV, you will document a problem list for the patient that can be used for the next 12-months. At each subsequent visit during the 12 months after the AWV, you should address elements of the problem list. Comprehensively capturing the patient's diagnoses throughout the year helps to ensure that Medicare is accurately understanding the patient's medical severity through the Hierarchical Condition Category (HCC) risk score. The HCC risk score is used in calculating payments to healthcare providers.

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 an 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 electronic health record (EHR) data to identify patients that qualify for IPPE or AWV.

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 (E/M) 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 patient's immediate issue at that time to provide the visit with no cost sharing. Some practices provide written materials to patients explaining the differences between the AWV and a physical exam prior to the visit.

Practices can use many modes to reach patients about the benefits of the AWV. Outreach can be provided in person (for example, community presentations, during office visit), 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.

What are the billing codes for AWVs?

There are three HCPCS codes for AWVs:

• G0438: AWV; includes a personalized prevention plan of service (PPS), initial visit. May be provided via telehealth.
• G0439: AWV, includes a personalized prevention plan of service (PPS), subsequent visit. May be provided via telehealth.
• G0468: An FQHC visit that includes an IPPE or AWV and includes the typical bundle of services that would be furnished per diem to a Medicare patient receiving an IPPE or AWV, including all services that would otherwise be billed as a FQHC visit under G0466 or G0467.

An SDOH Risk Assessment can be provided as an additional element of the AWV. Use CPT code G0136 (SDOH Risk Assessment) with modifier –33 on the same claim as the AWV for the same date of service as the AWV. An additional two CPT codes may be used for advance care planning:

• 99497: 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 health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate. May be provided via telehealth.
• 99498: 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). May be provided via telehealth.

Medicare will waive patient cost sharing requirements for advance care planning when provided on the same day, by the same provider, and on the same claim as the AWV.

Medicare will pay for a significant, separately identifiable, medically necessary E/M service along with the AWV for fee-for-service providers.

How do I document AWVs in my electronic health record (EHR)?

Many organizations have developed templates into their EHRs to capture all of the elements of the AWV. These templates include inputs for each component of this visit, including the health risk assessment, list of current practitioners, medical and family history, depression screening, fall risk assessment, and personalized prevention plan. The health risk assessment includes a patient questionnaire, which may be provided to the patient electronically or on paper and later transferred to the EHR. To reduce the length of the visit, some practices send the questionnaire to patients through a patient portal to complete prior to the visit. The information provided prior to the visit is then populated in the EHR.

Who in my organization should I engage when designing and implementing AWVs?

Implementing AWVs requires broad support, beginning with the medical staff and leadership. If completing AWVs is a priority for the practice, it will be successful. Members of the care team, from patient registration to nursing staff to the practitioner, should understand their role in the process and the workflow for completing the visit efficiently. Working with coding and billing staff early on is important for developing complete documentation and systems to bill for the service. Health information technology staff can build and refine IPPE/AWV templates and assist with queries to identify eligible patients.

Some clinics and practices establish performance improvement plans related to AWVs. These organizations establish benchmarks for the percentage of Medicare patients receiving an AWV and monitor and report on the goal regularly. For example, the clinic or practice may post results describing progress toward the AWV goal in a common area. Then, if the goal is achieved, it is important to celebrate the milestone.

How should I schedule staff to provide AWVs?

Each practice must determine the most efficient way to schedule AWVs. Due to the length of the 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. It may require some trial and error to determine the best approach for each practice.

Are there any special considerations for Rural Health Clinic (RHC) billing for AWVs?

AWVs can only be provided in an RHC setting by a practitioner that meets the RHC definition of a visit: physician, nurse practitioner, physician assistant, or certified nurse midwife.

RHCs billing for AWVs are reimbursed at their respective all-inclusive rate (AIR) and prospective payment system (PPS) rate. Cost sharing for patients is waived. If a significant, separately identifiable, medically necessary E/M service is provided along with the AWV, RHCs are not eligible for additional payment. The AWV cannot be billed as a separate RHC billable visit on the same day as a primary or preventive service visit. An AWV can only be billed as a stand-alone visit if it is the only medical service provided on that day with an RHC practitioner. Cost-sharing for patients will apply, just as it would for routine E/M visits without the AWV. RHCs are not eligible for the geographic adjustment factor and are unable to receive reimbursement for the Annual Wellness Visit (AWV) in conjunction with another service provided on the same day. An RHC visit falls under the AIR regardless of the number of services performed. As a result, RHCs can either perform the AWV on the same day as the other service and not receive AWV payment or have the patient return for a separate AWV visit.

Are there any special considerations for Federally Qualified Health Center (FQHC) billing for AWVs?

AWVs can only be provided in an FQHC setting by a practitioner that meets the FQHC definition of a visit: physician (MD or DO), nurse practitioner, physician assistant, or certified nurse midwife.

FQHCs billing for AWVs are reimbursed at their respective all-inclusive rate (AIR) and prospective payment system (PPS) rate. Cost sharing for patients is waived. If a significant, separately identifiable, medically necessary E/M service is provided along with the AWV, FQHCs are not eligible for additional payment. However, if an AWV occurs on the same day as another medical visit, the FQHC is eligible to receive a payment higher than their base rate. Additionally, the FQHC higher payment rate is calculated by applying the geographic adjustment factor of 1.3416 (or 34.16%) to the local FQHC base payment rate.

Resources

• Medicare Wellness Visits, CMS Medicare Learning Network
• Medicare's Annual Wellness Visit (AWV), American College of Physicians
• Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV), Noridian Healthcare Solutions
• Medicare Benefit Policy Manual - RHC and FQHC Update - Chapter 13, Centers for Medicare & Medicaid Services
• Medicare Claims Processing Manual, Chapter 9, Section 60.2 - Billing for FQHC Claims Paid under the PPS, Centers for Medicare & Medicaid Services
• Annual Wellness Visits (AWV) Video, Centers for Medicare & Medicaid Services
• Medicare Annual Wellness Visit (AWV): Streamline Workflow to Perform a Thorough AWV (Toolkit), American Medical Association
• How to Streamline Workflow for a Medicare Annual Wellness Visit, American Medical Association

Last Updated: 11/26/24
Last Reviewed: 11/26/2024