Medicare's wellness coverage offers critical services

Physicians must understand the requirements for billing for Medicare-covered preventive services, such as the “Welcome to Medicare” exam and Annual Wellness Visit (AWV).

In 2023, as always, ACP remains committed to elevating the role of both treatment and prevention. Providing equitable access to preventive services is an essential part of taking positive, proactive steps toward improving the nation's health. Medicare covers many preventive services to keep patients healthy, and it is critical that physicians discuss with patients which services are right for them and how often they need them.

While the importance of preventive services may be straightforward, billing for Medicare-covered preventive services, such as the “Welcome to Medicare” exam and Annual Wellness Visit (AWV), has its difficulties. Both the “Welcome to Medicare” exam and the AWV capitalize on a discussion about patients' health history, their risk factors for chronic diseases, and their current lifestyle, but the proper order and appropriate circumstances differ substantially. To best avoid denials when submitting claims, physicians must understand the requirements.

“Welcome to Medicare” visits

During the first 12 months a patient is enrolled in Medicare Part B (medical insurance), they are eligible for the “Welcome to Medicare” visit. This is a one-time visit that includes vital measurements, a vision screening, depression screening, and other assessments meant to gauge health and safety. Otherwise known as an Initial Preventive Physical Examination (IPPE) visit, its goals are health promotion and disease prevention and detection.

The “Welcome to Medicare” visit must be coded using G0402. Since this visit is restricted to those who have been enrolled for less than 12 months, once a patient has hit the 12-month mark, G0402 will be denied regardless of whether the IPPE visit previously took place.

Annual Wellness Visits

After a patient has been enrolled in Medicare for 12 months, they become eligible for an AWV. The AWV is a yearly visit to develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA). This service helps provide a clearer picture of the patient's health status from one year to the next, establishes a baseline, and provides longitudinal data to support the physician in managing changes. Medicare will cover an AWV providing a PPP for patients who:

  • are no longer within the 12-month period following the patient's Medicare eligibility date for Medicare Part B and
  • have not received an IPPE or AWV within the past 12 months.

Patients who completed an IPPE are eligible for the initial AWV on the first day of the same calendar month the following year. The initial AWV must be coded using G0438, with G0439 used to code all subsequent AWVs that occur after the initial AWV. If used correctly, then, G0439 would not be used until G0402 was used to code the IPPE and G0438 was used to code the initial AWV. If the patient never completed an IPPE, G0439 would still be used for any subsequent visits after G0438.

It is very important to note that while the AWV is similar to the IPPE, it includes slightly different required and accepted screenings, as well as separate codes. Since it is assumed that the different types of visits take varying amounts of practice resources, Medicare reimburses these services at different rates. For example, the initial AWV (G0438, RVU=2.60) is reimbursed at a rate that is over 35% higher than the subsequent AWV (G0439, RVU=1.92). This is because the initial AWV is used to collect the library of information that will continually be updated with each subsequent AWV. The result: If your practice regularly misses using the G0438 code for an initial AWV and uses G0439 instead, it could result in a significant loss of revenue.

Evaluation and Management (E/M) services

If the last three years of COVID-19 have taught us anything, it is that things rarely ever go as planned. In some instances, a patient is seen for a wellness visit and has acute symptoms or chronic problems, requiring additional evaluation. These encounters result in confusion about whether it is permissible to bill for the wellness visit and the acute or chronic care in the same visit. Often, usually to avoid audits, physicians are advised not to bill for both services; other times, they are told they can bill for both, but only one will be paid.

Though this guidance may be intended to guard against fraud, waste, or abuse, inappropriately downcoding results in significant amounts of uncompensated care. Physicians are not prohibited from coding and billing for both preventive and problem-focused E/M services when they are performed during the same appointment. Under these circumstances, it is imperative that physicians accurately and completely document all medically appropriate and necessary care and bill for what is documented. It is also important that the elements of the AWV not be replicated in the medically necessary service. In reporting this visit, the physician must append modifier 25 (significant, separately identifiable service) to the medically necessary E/M service to be paid for both. Of note, commercial payers may or may not cover the additional problem-focused E/M service, so physicians should be sure to check with their patients at the time of service to help avoid confusion and frustration related to unexpected charges.

ACP encourages physicians to visit its practice resources website to take advantage of its myriad resources designed to support practices in the provision of preventive services. Many patients think they do not need to see a physician unless they are sick; however, an annual visit is the best prescription for long-term health and wellness. To support your practice, ACP also offers a broad catalog of Medicare coding- and billing-related resources, including a new Coding for Clinicians subscription series, which features a learning module to properly report adult preventive medicine visits, the “Welcome to Medicare” visit, Medicare AWVs, and advance care planning codes. For additional information from CMS, please visit its Medicare Wellness Visits page.