Annual Wellness Visit (AWV) - Medicare

 HCPCS/CPT Codes

• 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

Who Is Covered

All Medicare beneficiaries who are both,

• Not within 12 months after the effective date of their first Medicare Part B coverage period
• Have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months

Frequently Used ICD

• Z00.00 - Encounter for general adult medical examination without abnormal findings
• Z00.01 - Encounter for general adult medical examination with abnormal findings
• Z00.121 - Encounter for routine child health examination with abnormal findings
• Z00.129 - Encounter for routine child health examination without abnormal findings

Frequency

• Once in a lifetime for G0438 (first AWV)
• Annually for G0439 (subsequent AWV)

Medicare Beneficiary Pays

• Co-payment/Coinsurance waived
• Deductible waived

Annual Preventive and Wellness Visit Service

Preventive Service Codes

The annual preventive exam is a periodic, comprehensive preventive medicine evaluation (or reevaluation) and management of the patient.

The CPT Code selection is based on whether the patient is receiving an initial visit -"New Patient" or a periodic - "Established Patient" preventive service, as well as the patient’s age.

• Initial Visits - 99381, 99382, 99383, 99384, 99385, 99386, 99387
• Subsequent Visits - 99391, 99392, 99393, 99394, 99395, 99396, 99397

The Medicare insurance would be covered by "G" codes instead of the above codes. The details below,

• Welcome to Medicare - G0402 (Within the one year from the patient enrolled in Medicare)
• Initial Annual Wellness Visit - G0438 (After the 1st year of enrollment)
• Subsequent Annual Wellness Visit - G0439

Initial Visits

Initial comprehensive preventive medicine evaluation and management of an individual including an" age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures", New patient,

• 99381 - Infant (age younger than 1 year)
• 99382 - Early childhood (age 1 through 4 years)
• 99383 - Late childhood (age 5 through 11 years)
• 99384 - Adolescent (age 12 through 17 years)
• 99385 - 18-39 years
• 99386 - 40-64 years
• 99387 - 65 years and older

Subsequent Visits

Periodic comprehensive preventive medicine reevaluation and management of an individual including an "age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures," established patient,

• 99391 - Infant (age younger than 1 year)
• 99392 - Early childhood (age 1 through 4 years)
• 99393 - Late childhood (age 5 through 11 years)
• 99394 - Adolescent (age 12 through 17 years)
• 99395 - 18-39 years
• 99396 - 40-64 years
• 99397 - 65 years and older

Included Services

Checking the status of "chronic conditions" and "refilling ongoing prescriptions" is expected during an annual preventive exam and does not warrant the billing of a separate problem-oriented E/M service.

If a chronic condition is not being well controlled, however, and decisions are being made as to how to treat the patient to improve control (changing the dosage of medications, changing to a new medication, etc.), this may substantiate a separate problem-oriented E/M service.

Documentation

• Medical and family history
• List of current medical providers
• Height, weight, BMI, BP, and other appropriate routine measurements
• Detection of cognitive impairment
• Review risk factors – Review of functional ability
• Establish a written screening schedule for the next 5-10 years
• Establish a list of risk factors
• Provide advice and referrals to health education and preventative counseling services

Tips - CPT G0402 & G0438 covered once in a lifetime for the patient.

See E/M 2021E&M guidelines