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Annual Wellness Exam
Pursuant to section 4103 of the Affordable Care Act of 2010 (the ACA), the Centers for Medicare & Medicaid Services (CMS) amended section 42 CFR 411.15(a)(1) and 42 CFR 411.15(k)(15) (list of examples of routine physical examinations excluded from coverage), effective for services furnished on or after January 1, 2011.
This expanded coverage is subject to certain eligibility and other limitations that allow payment for an annual wellness visit (AWV) providing personalized prevention plan services (PPPS), when performed by a health professional (as defined in this section), for an individual who is no longer within twelve (12) months after 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 twelve (12) months. Medicare coinsurance and Part B deductibles do not apply.
The AWV will include the establishment of, or update to, the individual’s medical/family history, measurement of his/her height, weight, body-mass index (BMI) or waist circumference, and blood pressure (BP), with the goal of health promotion and disease detection and encouraging patients to obtain the screening and preventive services that may already be covered and paid for under Medicare Part B. Definitions relative to the AWV are included below.
Coverage is available for an AWV that meets the following requirements:
Healthcare Common Procedure Coding System (HCPCS) Coding for the AWV
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
Definitions Related to the AWV
Detection of any cognitive impairment: The assessment of an individual’s cognitive function by direct observation, with due consideration of information obtained by way of patient reports, concerns raised by family members, friends, caretakers, or others.
Eligible beneficiary: An individual who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period and who has not received either an IPPE or an AWV providing PPPS within the past 12 months.
Establishment of, or an update to, the individual’s medical/family history: At a minimum, the collection and documentation of the following:
First AWV providing PPPS: The provision of the following services to an eligible beneficiary by a health professional that include, and take into account the results of, a health risk assessment as those terms are defined in this section:
Health Risk Assessment means, for the purposes of the annual wellness visit, an evaluation tool that meets the following criteria:
Review of the individual’s functional ability and level of safety: At a minimum, includes assessment of the following topics:
Subsequent AWV providing PPPS: The provision of the following services to an eligible beneficiary by a health professional that include, and take into account the results of an updated health risk assessment, as those terms are defined in this section:
Advance Care Planning (ACP) as an Optional Element of an Annual Wellness Visit (AWV)
For services furnished on or after January 1, 2016, Advance Care Planning (ACP) is treated as a preventive service when furnished with an AWV. The Medicare coinsurance and Part B deductible are waived for ACP when furnished as an optional element of an AWV.
The codes for the optional ACP services furnished as part of an AWV are 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;) and an add-on code 99498 (each additional 30 minutes (List separately in addition to code for primary procedure)). When ACP services are provided as a part of an AWV, practitioners would report CPT code 99497 (and add-on CPT code 99498 when applicable) for the ACP services in addition to either of the AWV codes (G0438 or G0439).
The deductible and coinsurance for ACP will only be waived when billed with modifier 33 on the same day and on the same claim as an AWV (code G0438 or G0439), and must also be furnished by the same provider. Waiver of the deductible and coinsurance for ACP is limited to once per year. Payment for an AWV is limited to once per year. If the AWV billed with ACP is denied for exceeding the once per year limit, the deductible and coinsurance will be applied to the ACP.