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CPT Codes for Annual Wellness Visits

Annual Wellness Visits (AWV) are a type of preventive care for Medicare patients. There are many benefits to implementing this type of program, such as improving patient outcomes and filling in gaps in care. However, you must understand the CPT billing codes to ensure your claims are not denied and help drive revenue at your organization.

What Is the CPT Code for Annual Wellness Visits?

There are generally three codes associated with Annual Wellness Visits representing distinct phases in AWV programs:

• G0402: This code applies to the Welcome to Medicare visit — also referred to as an Initial Preventive Physical Exam (IPPE). This exam is not an Annual Wellness Visit, but it is valuable for understanding the framework of an AWV program. A patient is only eligible for the first 12 months they are enrolled in Medicare. This one-time visit focuses on gaining a general understanding of health with a vision screen, vital measurements and other assessments. This code will be rejected if you apply it after the 12-month mark of enrollment.
• G0438: After 12 months of being enrolled in Medicare, a patient becomes eligible for their initial Annual Wellness Visit. If a patient completes an IPPE, they are permitted to use this initial visit on the first day of the same calendar month the next year. When a patient does not complete IPPE, this code will apply any time after the 12-month mark.
• G0439: You must use this code for all Annual Wellness Visits following the initial one. Among the AWV codes, this is the last one you will use, and it's the only one you will use repeatedly. 

There are various factors that define an Annual Wellness Visit. There are even differentiators between the initial AWV and all subsequent AWVs. However, you should first make sure you understand the difference between an Annual Wellness Visit and an annual physical.

Requirements and Components for Billing AWV

The requirements and components for an AWV vary based on whether you apply G0438 or G0439.

The G0438 requirements include:

• A Health Risk Assessment (HRA)
• Medical and family history
• List of current providers involved in the patient's health
• Cognitive function assessment
• Blood pressure, height, weight, body mass index and other appropriate measurements
• Risk factors for depression
• Functional ability and safety assessment
• Screening schedule creation
• Risk factors and conditions
• Personalized health advice
• Advance Care Planning, if desired

The G0439 requirements involve updating all of the above factors. Additionally, the patient must not have received an Annual Wellness Visit in the last 12 months. 

Who Can Bill AWV Codes?

Unlike some other billing codes under CMS, Annual Wellness Visit billing does have some flexibility. Practices do not need to hire additional staff for their AWV program, and physicians do not have to be the only professionals involved. Rather than assigning specific tasks and responsibilities to different team members, CMS allows for AWV coverage with any of the following individuals:

• A physician
• A physician assistant (PA)
• A nurse practitioner (NP)
• A certified clinical nurse specialist (CNS)
• A medical professional or team under a physician's supervision, such as registered dieticians or health educators

AWV billing is also not limited to primary care providers. Select specialty practices can bill for AWVs, such as neurology and cardiology. Regardless of who bills the AWV with CMS, a person is only permitted to receive one AWV per year. For instance, a cardiologist cannot bill for an AWV two months after a primary care provider did — the claim will be denied.

It's not unusual for Medicare patients to see one or more specialists, which can lead to AWV billing conflict. Having a real-time system in place to check eligibility can be a major advantage to all care providers.

Additional AWV Codes

At ChartSpan, we provide eligibility checks for G0438 and G0439 — the core codes for Annual Wellness Visits. However, some AWVs may involve additional codes depending on a patient's needs. Examples of additional codes include:

• 99497: Advance Care Planning is an optional element of an AWV, and it includes a discussion about advance directives and other care wishes. The co-pay is waived when it's billed on the same day as an AWV.
• G0442 and G0443: These codes must be used together, and they apply to an Annual Alcohol Screening and 15-minute alcohol counseling session, respectively.
• G0477: This code is for a 15-minute obesity counseling session and it can be billed with IPPE or an AWV. 
• G0153 and G0154: When an AWV takes longer than the typical service, these codes can be added for prolonged preventive services. The codes represent an extra 30 minutes and an additional 60 minutes, respectively.

Talking About AWV With Medicare Patients

Introducing an AWV program at your practice can help you shift from the Fee-for-Service model to Value-Based Care (VBC). AWV programs contribute to the VBC model because your practice receives payments based on patient health outcomes. Since AWVs are a form of preventive care, you can identify risk factors in your Medicare patients and take action on those factors to improve patient outcomes and close gaps in care.

The VBC model offers benefits to all parties involved in the healthcare system. Patients spend less to maintain their health, and providers can increase patient satisfaction to keep them coming back for appointments. While practices have to spend more time on preventive care, the time saved on chronic disease management is meaningful. Payers then reduce risks and have stronger cost controls. 

When discussing the Annual Wellness Visit with your patients, remind them that this type of preventive care reduces the risk of more severe disease and can improve their quality of life in the long term. 

Grow Your Medicare AWV Program With ChartSpan

Annual Wellness Visits offer advantages at many stages in the healthcare system, but they still come with challenges. The greatest hurdle your practice faces is patient eligibility. With specialists and primary care providers capable of billing for these visits, a patient may have already had an AWV without you knowing. Providing AWV services and being denied can diminish the value of the program itself.

At ChartSpan, we have a software solution that supports eligibility checks for your AWV program. RapidAWV™ starts by identifying eligible Medicare patients as they come in for their regularly scheduled appointments. From there, the system checks the HIPAA Eligibility Transaction System (HETS) to determine if a patient has had an AWV with any other provider.

This process allows providers to bill for an AWV when they can guarantee reimbursement rather than being denied following a claim. With our team supporting this function through patient engagement and interaction, your overall approach to billing and care becomes more efficient. Improve patient outcomes, close gaps in care and introduce a VBC model with ease. 

Learn more about ChartSpan or contact us to get started with our software.