Set the record straight with patients to prevent surprise billing.
If you work in a medical billing office, you know how frustrating it can be to get a phone call from a patient asking why they are getting a bill for their “free” visit. The patient is frustrated because they do not understand the components of an annual wellness visit (AWV) for Medicare patients. “You know that laundry list of health issues you created over the year and addressed with the clinician during your visit? Sorry, but that’s not included in the AWV,” you tell the patient. Invariably, this does not go over well. Ultimately, it’s your job to prevent this sort of misunderstanding from the get-go.
In this article, we’ll review what Medicare AWVs include and don’t include and their frequency limitations. This information is changeable, so even the most experienced coders, billers, and auditors should periodically review the definitions for Medicare’s physical exams coverage.
The Initial Preventive Physical Exam
It’s important not to confuse the various types of physical exams Medicare allows because they are coded differently and coverage may vary, as well.
When an individual initially signs up for Medicare, they have the option of receiving an initial preventive physical exam (IPPE) at no extra cost to them. They are eligible for this “Welcome to Medicare” preventive visit within the first 12 months of enrollment. This benefit is a once-in-a-lifetime “use it or lose it” service. Patients should be encouraged to take advantage of the IPPE, as it is a beneficial service. The IPPE aims to promote a healthy lifestyle, prevent and detect disease, identify areas of concern, and provide education and counseling to ensure the patient is well informed and understands what services are covered by Medicare. The IPPE can be performed by a physician or other qualified healthcare professional (QHP).
There are eight areas in the IPPE that the provider is supposed to address and document, as shown in Table A.
What Codes Are Billed for the IPPE?
The IPPE is a proprietary Medicare service for which you will bill the contractor using HCPCS Level II codes.
G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
G0403 Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and reportG0404 Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination
G0405 Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination
G0468 Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV
There is not a specific ICD-10-CM code designated by Medicare to use with the IPPE. You may choose a diagnosis code addressed during the visit or use a code from category Z00-Z09 Factors influencing health status and contact with health services.
The Annual Wellness Visit
The purpose of the AWV is to develop or update a personalized prevention health plan and perform a health risk assessment (HRA). As with the IPPE, the patient will not cost share (if the provider accepts assignment) and the deductible does not apply. New Medicare beneficiaries are eligible for one initial AWV. The patient can receive this service one time after the first 12 months of their Medicare enrollment. It does not have to be in the second year of enrollment. It could be years later, but they only receive it one time.
After the initial AWV, the patient qualifies for subsequent AWVs each year (after a full 11 months have passed from the previous AWV). Many get confused about the timing of the subsequent visit. The easiest way to explain it is that patients can have their next subsequent AWV anytime within the same month of their previous visit the year before, or later.
For example: If a patient receives their subsequent AWV on June 15, 2021, they will be eligible to receive their next subsequent AWV on June 1, 2022. You do not count June 15, 2021, because it is not a “full” month. You start counting in July and stop the end of May for 11 full months.
Who Can Perform an AWV?
Only certain practitioners are permitted to perform AWVs. These include:
- Qualified non-physician practitioners (NPPs)
- Other QHPs – health educator, registered dietician, nutrition professional, other licensed practitioner, or a team of medical professionals directly supervised by a physician
As usual, state licensing applies, as well.
Here are answers to a few frequently asked questions about annual wellness visits (AWVs) and initial preventive physical exams (IPPEs).
Are the IPPE and AWV the same as the routine yearly physical exam?
No. Bill routine yearly physical exams using the CPT® Evaluation and Management (E/M) codes. Medicare does not cover routine yearly physical exams.
Can the AWV and IPPE be performed via telehealth?
The IPPE cannot be performed via telehealth, but initial and subsequent AWVs may be performed via telehealth.
Can AWVs and IPPEs be performed at the same time as another E/M service to address medical conditions?
Yes, if the additional visit documented supports a significant separately identifiable service, you can report 99202-99215 in addition to the AWV. Best practice is to let the patient know that if the provider addresses additional conditions, they may receive a bill for the added service.
What Codes Are Billed for the AWV?
G0438 Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit
G0439 Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit
There is not a specific ICD-10-CM code designated by Medicare to use with the AWV. You may choose a diagnosis code addressed during the visit or use a code from Z00-Z99.
See Table B for a comparison of what is required for the initial AWV versus subsequent AWVs.
Advance Care Planning May Be Separate
Advance care planning (ACP) can be provided during an AWV or covered as a separate Part B service, when medically necessary. In either case, when performed at length (30 minutes or more), it is separately billable.
This service is when the provider and the patient discuss the patient’s end-of-life treatment wishes in the event a time comes when the patient cannot speak or make their own decisions about the care they wish to receive or not receive. There is no limit on the number of times a provider can report ACP for a patient, but the service may only be provided when the patient agrees to receive the service.
Make sure the patient understands when ACP is non-covered; ACP is covered once per year with no cost sharing to the patient; if the ACP is provided outside of the timeframe, the patient will cost share and pay their deductible and coinsurance (if applicable). Medicare will waive the coinsurance and deductible when provided during an AWV if the following occur:
- ACP is provided on the same date as the covered AWV.
- ACP is provided by the same provider as the covered AWV.
- ACP is billed with modifier 33 Preventive services.
The provider must document the change in the patients’ health and wishes for end-of-life care.
What Codes Are Billed for Advance Care Planning?
When reporting ACP services beyond what is included in the AWV, you will report the following CPT® codes, as applicable:
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 are professional, first 30 minutes, face to face with the patient, family member(s), and/or surrogate
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 health are professional; each additional 30 minutes (List separately in addition to code for primary procedure)
Report the diagnosis code(s) in support of this service based on the patient’s documented exam findings.
Preventive Care Starts With You
Medicare eligible patients should be encouraged to take advantage of the Medicare AWV each year to help detect or prevent diseases that may otherwise go unnoticed or untreated. Many patients do not understand that their “free” visits have limitations, however. Although patients may not like to be billed for added services performed during the AWV, they will be far less upset if they know what to expect. On the bright side, you can say, having the additional conditions addressed at the same time as their AWV will prevent them from having to return to the office on a later date.