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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:

    • It is performed by a health professional; and,
    • It is furnished to an eligible beneficiary who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and he/she has not received either an IPPE or an AWV providing PPPS within the past 12 months.

Eligible Providers

    • A physician who is a doctor of medicine or osteopathy; or,
    • A physician assistant, nurse practitioner, or clinical nurse specialist; or,
    • A medical professional (including a health educator, registered dietitian, or nutrition professional or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician as defined in this section.

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:

    • Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments.
    • Use or exposure to medications and supplements, including calcium and vitamins.
    • Medical events in the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the individual at increased risk.

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:

    • Review (and administration if needed) of a health risk assessment (as defined in this section).
    • Establishment of an individual’s medical/family history.
    • Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.
    • Measurement of an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history.
    • Detection of any cognitive impairment that the individual may have as defined in this section. f. Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations.
    • Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations.
    • Establishment of the following:
      • A written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), and the individual’s health risk assessment (as that term is defined in this section), the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
      • A list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
    • Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote selfmanagement and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
    • Any other element determined appropriate through the National Coverage Determination (NCD) process.

Health Risk Assessment means, for the purposes of the annual wellness visit, an evaluation tool that meets the following criteria:

    • Collects self-reported information about the beneficiary.
    • Can be administered independently by the beneficiary or administered by a health professional prior to or as part of the AWV encounter.
    •   Is appropriately tailored to and takes into account the communication needs of underserved populations, persons with limited English proficiency, and persons with health literacy needs.
    • Takes no more than 20 minutes to complete.
    • Addresses, at a minimum, the following topics:
      • Demographic data, including but not limited to age, gender, race, and ethnicity.
      • Self assessment of health status, frailty, and physical functioning.
      • Psychosocial risks, including but not limited to, depression/life satisfaction, stress, anger, loneliness/social isolation, pain, and fatigue.
      • Behavioral risks, including but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (seat belt use), and home safety.
      • Activities of daily living (ADLs), including but not limited to, dressing, feeding, toileting, grooming, physical ambulation (including balance/risk of falls), and bathing.
      • Instrumental activities of daily living (IADLs), including but not limited to, shopping, food preparation, using the telephone, housekeeping, laundry, mode of transportation, responsibility for own medications, and ability to handle finances.

Review of the individual’s functional ability and level of safety: At a minimum, includes assessment of the following topics:

    • Hearing impairment,
    • Ability to successfully perform activities of daily living,
    • Fall risk, and,
    • Home safety.

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:

    • Review (and administration if needed) of an updated health risk assessment (as defined in this section).
    • An update of the individual’s medical/family history.
    • An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing PPPS or the previous subsequent AWV providing PPPS.
    • Measurement of an individual’s weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individual’s medical/family history.
    • Detection of any cognitive impairment that the individual may have as defined in this section.
    • An update to the following:
      • The written screening schedule for the individual as that schedule is defined in this section, that was developed at the first AWV providing PPPS, and,
      • The list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, as that list was developed at the first AWV providing PPPS or the previous subsequent AWV providing PPPS.
    • Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs as that advice and related services are defined for the first AWV providing PPPS.
    • Any other element determined appropriate by the Secretary through the NCD process.

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.



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