Annual wellness visits (AWV) have become key to healthcare delivery in the United States, and integral to the Medicare reimbursement model. Applicable to millions of Americans, AWVs represent a major opportunity to boost quality of care, as well as expand touchpoints, referral relationships and other business goals. Best of all, telehealth technology has significantly expanded the availability and cost effectiveness of these visits for providers of all types.
What are Medicare annual wellness visits?
What is an annual wellness visit? Also called an AWV, an annual wellness visit is a Medicare-defined protocol for Part B beneficiaries to receive yearly preventive care exams. According to the most recent guide from the Centers for Medicare & Medicaid Services (CMS), the purpose of these exams is to “develop or update” a personalized prevention plan (PPP) and perform a health risk assessment (HRA).
Available for free to Medicare Part B beneficiaries, annual wellness visits are about “taking a comprehensive look at the patient, finding and addressing care needs, and making a plan to help keep them healthy,” according to a white paper sponsored by Caravan Health and published online by the American College of Physicians® (ACP).
As such, annual wellness visits are different from other Medicare physical exams. Unlike the initial preventive physical exam (IPPE), which is covered just once for new Part B enrollees, annual wellness visits recur each year. And they can’t be used as a substitute for a routine physical examination “without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.”
But, though the definitions concerning annual wellness visits are straightforward and rigidly defined, the benefits can also extend far beyond them. AWVs can help boost care standards by providing “a more comprehensive assessment of the patient’s health and wellbeing,” as the white paper points out. They also offer a chance to “identify patients who would benefit from Chronic Care Management (CCM).”
Beyond preventive screening for health risks, other circumstances may allow for annual wellness visits to be billed in conjunction with other health treatments. This requires “a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service,” in which “Medicare may pay the additional service,” the CMS manual explains.
So, as part of Medicare’s Part B preventive services, these yearly visits are part of a suite of services that also focus on preventive screenings and related services like vaccination, counseling and self-management training. The idea is to enable patients to better understand what to do to stay healthy, and to give providers more opportunities to detect potential health issues.
As such, annual wellness visits have become a useful way to boost the standards of patient care, and to work for improved outcomes. They can help add to the information that enables population health management services like CCM. They also offer opportunities for providers to more closely manage a patient’s health, and to receive reimbursement for more active and proactive care.
How to bill for annual wellness visits, and what codes to use
Billing for annual wellness visits currently involves three separate HCPCS codes.
- G0468 can be used to cover the first annual wellness visit for new beneficiaries (those who enrolled in Part B for fewer than 12 months. It can also cover a federally qualified health center (FQHC) visit or IPPE, which, as noted above, is an initial visit for a new beneficiary.
- G0438 covers the first annual wellness visit for beneficiaries who do not qualify for G0468 — in other words, those who have been enrolled in Part B for more than 12 months. It cannot be used for a patient who’s received an IPPE or AWS from G0468 within the previous 12 months. G0438 is intended to facilitate the creation of a personalized prevention plan of service (PPS).
- G0439 offers coverage for each subsequent visit after the use of G0438, but must be billed in the following 12-month period. Like G0438, the stated goal of G0439 is to support or revise the beneficiary’s personalized prevention plan of service (PPS).
These are often as straightforward as they seem. However, denied claims due to improper coding are not infrequent. If records aren’t well kept and organized, a patient’s prior clinical history can be easily overlooked. And even if a patient is new to a doctor, their billing codes must align with their past history as a Medicare beneficiary — information that’s not always readily available to current providers.
For example, billing G0438 or G0439 instead of G0402 (initial preventive physical exam, or IPPE) for new beneficiaries is a common mistake, notes the American Academy of Family Physicians (AAFP). So is billing for annual wellness visits for patient on Medicare Part A (they must be on Part B to be eligible).
“You can only bill G0438 or G0439 once in a 12-month period,” the CMS manual points out. It also advises providers not to bill “G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient,” since that will result in a denied claim.
It’s also important to separate annual wellness visits from “problem-oriented” diagnosis codes, such as those associated with diabetes, hypertension or other potential chronic conditions. In these cases, the AAFP advises listing “a well code (e.g., Z00.0X, ‘encounter for general adult exam’) as the primary diagnosis.”
However, as noted above, CMS does allow for the concurrent billing of annual wellness visits with some of these other evaluation and management (E&M) services, as long as they’re “medically necessary and reasonable to treat the patient’s illness or injury, or to improve the functioning of a malformed body part.” In these instances, CMS advises reporting “the additional CPT code with modifier –25.”
Finally, these annual wellness visits can, and often should, be paired with other Part B preventive services in the interest of advance care planning services. These can include cancer screenings, depression screenings, tobacco use counseling, and a variety of other options. Refer to the CMS guide for a full list of these services.
The benefits of combining telehealth with annual wellness visits
Thanks to technological advancements, many of the components of an annual wellness visit can now be delivered using telehealth technology. And since Covid-19 ushered in the need for more at-home medical care services, the use of telehealth for annual wellness visits has grown tremendously.
And with good reason! As the Caravan Health white paper points out, telehealth annual wellness visits allow “care teams to proactively engage patients, help them avoid risky health behaviors, and identify and meet care needs before they become acute enough to require the patient to access an in-person healthcare setting, such as urgent care or the emergency department.”
Practically speaking, using telehealth technology to actually deliver annual wellness visits is also straightforward. “Although there may be some workflow changes, many of the components of the AWV can be readily adapted to a virtual environment,” according to the Caravan white paper.
For instance, today’s real-time audio and video technology can help patients more easily speak with doctors and caregivers. Using virtual visit technology, primary care providers and other qualified health professionals can speak directly to patients while also seeing them on screen. (Telephone-only annual wellness visits are not yet allowed.)
Using these virtual visits, and other methods like ePRO (electronic patient-reported outcomes) technology, providers and care teams can get the answers to a wide variety of applicable patient questions. This includes not just their current health and mental health status, but also family history, habits of daily living, and even basic measurements like waist circumference and weight (with the help of medical devices like an RPM weight scale).
In addition, current CMS rules allow for a doctor’s clinical staff to administer these telehealth annual wellness visits without direct supervision, if one or two criteria or met: “First, the provider and clinical staff may be in the same physical location (such as an office suite),” the white paper notes. “Alternatively, the provider” can also be able to “immediately join the audio and video telehealth visit.”
The use of telehealth for annual wellness visits peaked sharply during Covid-19, and that trend has not gone unnoticed. The national public health emergency (PHE) ushered in by the pandemic is still active, meaning that some key telehealth provisions to enable telehealth access re in place. These include waiving geographical restrictions and the requirement for the patient to travel to an originating site.
Though these waived requirements were designed to “helps protect patients and providers from the spread of the virus and “reduces use of personal protective equipment” they have proved so useful, and so popular with patients, that they’re still in place. And lawmakers are actively lobbying to extend them through 2024.
Looking for help setting up telehealth annual wellness visits?
If you’re seeking more info on how to leverage telehealth to better meet your patient care goals, we’re standing by to help! Contact CareSimple today to connect with an expert.
And for a full rundown of reimbursement codes for CCM and other models of care using telehealth technology, download our CareSimple Reimbursement Tree for a handy, one-page summary.