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Medical Coding News Archives

Medicare Covers Annual Wellness Visits Beginning January 1

 
December 23, 2010:

As required by the Affordable Care Act (ACA), Medicare will cover an annual wellness visit (AWV) with personalized prevention plan effective January 1. However, before billing for the service, providers must know what specific requirements must be met.

The service is covered only when performed by specific providers, including:

  • A physician who is a doctor of medicine or osteopathy
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Medical professional (including a health educator, registered dietitian, or nutritionist)
  • A team of medical professionals, who are working under the supervision of a physician

During the first AWV, the personalized prevention plan should include:

  • Establishment of an individual's medical and family history
  • Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual as well as medications prescribed for the individual
  • Measurement of an individual's height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history
  • Detection of any cognitive impairment the individual may have must include establishment or updating of a screening schedule for the next five to 10 years, as well as, at a minimum, assessment of:
    • hearing impairment
    • ability to perform activities of daily living
    • risk of fall
    • home safety
  • 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 those without a current diagnosis of depression. The health care professional may select from various available screening questions or standardized questionnaires recognized by national professional medical organizations as appropriate for assessing risk for depression.
  • Review of the individual's functional ability and level of safety, based on direct observation or the use of appropriate screening questions or questionnaire. The health care 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, such as a checklist, for the next five to 10 years as appropriate, based on recommendations of the U.S. Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices, and the individual's health status and screening history
    • 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, including any mental health conditions or any such risk factors or conditions that have been identified through an initial preventive physical examination (as described under §410.16), 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 self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition
  • Any other element determined appropriate through the national coverage determination process

Subsequent AWVs that offer personalized services for prevention plans under this benefit include the following:

  • An update of the individual's medical and 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 that included personalized prevention plan services
  • Measurement of an individual's weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history
  • Detection of any cognitive impairment the individual may have
  • An update to both of the following:
    • The written screening schedule for the individual as that schedule was developed at the first AWV that included personalized prevention plan services
    • The list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual as that list was developed at the first AWV that included personalized prevention plan services
  • Furnishing of personalized health advice to the individual and a referral, as part of that advice and as appropriate, to health education or preventive counseling services or programs and related services
  • Any other element determined through the NCD process

Coding AWV Services CMS established two new HCPCS Level II codes for reporting these services:

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

When the provider must also treat acute or chronic conditions, he or she may also report the appropriate evaluation and management (E/M) service. Documentation must support the key elements of the E/M service as well as the medical necessity of the visit. In these situations, modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to the E/M code to designate the E/M visit as a separately identifiable service from the initial or subsequent AWV.

Under provisions included in the ACA, Medicare will reimburse 100 percent of either the actual charge or the fee schedule payment amount, whichever is less. Additionally, the patient deductible does not apply to the service.

Deborah C. Hall
Clinical/Technical Editor

 

 
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