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The Ultimate Guide to Medicare Annual Wellness Visits

Jon-Michial Carter
Written by Jon-Michial Carter

The Medicare Annual Wellness Visit (AWV) is a valuable but often underutilized resource. This annual checkup, specifically designed for Medicare beneficiaries, encourages proactive health management, creates customized preventive care plans, and promotes improved quality of life for the recipients. 

Studies have demonstrated the enormous opportunity for AWVs to facilitate healthy aging among the elderly populace and encourage participants to take advantage of preventive services and mitigate their health risks. AWVs also correlate to a significant reduction in acute hospitalizations and outpatient services, as Medicare patients average a 5.7% reduction in healthcare expenditures if they receive an AWV. 

However, 81% of eligible participants fail to receive the service despite its potential to enhance overall well-being. Patients and providers are often confused about the distinction between AWVs and annual physicals. Furthermore, AWVs can be perceived as disruptive to a practice’s workflow without proper implementation. If practices cannot verify patient eligibility in real-time, they also risk providing a service that does not qualify for reimbursement. 

In this article, we delve into the vital aspects of AWVs, defining the specifics of what an AWV entails, what makes them distinct from other routine annual visits, and how to seamlessly integrate them into your practice through ChartSpan’s RapidAWV™ software. 

What is a Medicare Annual Wellness Visit?

Medicare Annual Wellness Visit (AWV) is a yearly appointment where healthcare providers assess a patient’s health risks, develop personalized prevention plans, recommend screenings, and educate patients on managing their health. AWVs provide customized preventive care, detect potential health risks early on, actively engage patients in their wellness journey, and improve patients’ overall quality of life. 

First introduced in 2011 as part of the Affordable Care Act, Annual Wellness Visits are entirely covered by Medicare and scheduled every 12 months once a patient has been enrolled in Medicare Part B for over a year. 

What happens at an Annual Wellness Visit?

During an Annual Wellness Visit, physicians will review a patient’s medical history and prescription medications and document vital signs like height, weight, body mass index (BMI), and blood pressure. Before the physician’s consultation, patients complete a Health Risk Assessment (HRA), a self-guided questionnaire that ascertains details about the patient’s health, medical history, and lifestyle. AWVs also address various factors that influence a patient’s health, like behavioral risks, cognitive ability, depression, nutrition, and Social Determinants of Health (SDOHs)

Annual Wellness Visits are intentionally proactive and designed to promote positive clinical outcomes and quality of life by holistically observing a patient’s health and risk factors. Suppose a patient is living with a chronic illness like diabetes. In that case, the focus of many office visits and yearly examinations may be tied to the patient’s symptoms and concerns about their condition and medications. 

Other risk factors may go undetected during sick-care visits, leading to the patient developing additional chronic conditions that further complicate their healthcare journey. Through HRAs and AWVs, physicians can observe a patient’s unique medical history, risk factors, and lifestyle and gain a better understanding of what conditions patients may struggle with in the future. 

Physicians then craft an individualized wellness plan that mitigates health risks and emphasizes preventive action, rather than solely treating the existing symptoms and concerns. 

These preventive health plans promote optimal quality of life for the patient by avoiding injury and disease, minimizing functional decline, and eliminating any outstanding gaps in care

Learn more: Why Do So Many Providers Fail to Capture AWVs?

What is included in a Medicare Annual Wellness Visit?

A Medicare Annual Wellness Visit may consist of: 

  • Providing a patient with a Health Risk Assessment (HRA)
  • Measuring a patient’s height, weight, BMI, blood pressure, and other relevant metrics
  • Documenting a patient’s personal and family medical history 
  • Reviewing a patient’s current medications, healthcare providers, vitamins, and supplements
  • Evaluating a patient’s cognitive function and risk for impairments like dementia or Alzheimer’s
  • Checking a patient’s functional abilities (dressing, bathing, using the bathroom, etc.) 
  • Identifying risk factors, including fall risk assessments, behavioral risks like smoking, sedentary lifestyle, poor nutrition, and other limitations or lifestyle factors that may complicate a patient’s long-term health
  • Administering a behavioral health screening for depression
  • Discussing Social Determinants of Health (SDOHs) with a patient 
  • Providing a patient with personalized health advice for identified risk factors, including resources for exercise, weight management, substance abuse, or smoking cessation
  • Discussing Advance Care Planning 
  • Reviewing any opioid medications a patient may be taking 
  • Creating a personalized schedule of health screenings and recommended tests based on a patient’s age, medical history, and unique risk factors

Some of the information obtained during an AWV may lead to additional appointments where more robust examinations occur. For example, suppose a physician notices a patient is exhibiting worrisome cognitive issues. In that case, they may schedule a follow-up appointment where they perform more thorough tests for dementia, Alzheimer’s, memory loss, and related behavioral health concerns like anxiety and depression. 

Similarly, a physician may recommend follow-up immunizations, cancer screenings, and lab tests based on information obtained through the HRA and subsequent patient dialogue. These follow-up appointments are a part of the preventive care plan presented to the patient after the AWV. The AWV does not cover these services, and this information should be clearly communicated to patients to minimize confusion.

However, AWVs can be billed concurrently with problem visits, which is one of the most effective ways to integrate AWVs smoothly into a practice’s pre-existing workflow. When practices can efficiently combine sick visits with the administration of AWVs, they maximize revenue for the visit without sacrificing additional practice resources, demanding additional appointments from the patient, or running the risk of patients skipping the preventive care appointment. (This last point is a particular concern, as studies have shown up to 41% of preventive care appointments result in patient no-shows.)

Learn more: The Ultimate Annual Wellness Checklist for Providers

What is not included in an Annual Wellness Visit?

Medicare’s Annual Wellness Visits aim to develop preventive care plans rather than address pre-existing health concerns or be used for routine examinations. Therefore, AWVs do not include:  

  • Any physical examination of the patient (beyond collecting standard metrics like weight and height) 
  • Any blood work, x-rays, or lab tests 
  • Treatment of chronic conditions like high blood pressure, diabetes, or arthritis 
  • Evaluating, diagnosing, or creating a treatment plan for any new illness or symptom
  • Prescription of new medications or adjusting existing medications 
  • Performing immunizations

AWVs are not intended to diagnose conditions, treat pre-existing chronic illnesses, or include a hands-on physical examination of the patient. If patients have specific concerns related to their physical health, like new or worsening symptoms, a separate appointment will be necessary to analyze and address these issues thoroughly.

If a provider administers any of these services or other diagnostic care during the appointment, patients should expect a coinsurance or copayment, as these services are explicitly not covered under Medicare’s provisions for preventive AWVs. 

How is the AWV distinct from an Annual Physical?

While an AWV is similar to an annual physical exam and the Initial Preventive Physical Exam (IPPE), also known as the Welcome to Medicare preventive visit, an AWV is a separate service. AWVs have unique billing codes, Medicare-determined criteria, and a distinct purpose. 

Annual Wellness Visits are focused on creating preventive health plans for patients and do not include physical examination, lab work, or immunization. An Annual Wellness Visit’s primary purpose is for the patient to complete a Health Risk Assessment and for the physician to develop or update a Personalized Prevention Plan (PPP), according to the Centers for Medicare & Medicaid Services (CMS) documentation. 

An annual physical exam obtains a clear assessment of the overall state of a patient’s health, observes organ functionality, screens for common types of cancer, and keeps patients up-to-date on recommended vaccinations. Medicare does not cover annual physical exams, but they do cover 100% of AWVs for eligible participants. If a patient is treated for concerns that extend beyond the scope of an AWV, these services will be billed to a patient’s insurance, which may result in unplanned out-of-pocket costs.

Patients often need to be made aware of the distinction between AWVs and annual physical exams. If patients do not understand the intention of an AWV, it can lead to confusion, frustration, and dissatisfaction. Physicians must communicate with patients about what to expect during an AWV and the intended outcomes of the appointment. 

Likewise, physicians are often unsure about what an AWV covers and what requires a distinct appointment, which may discourage them from promoting the service to their patients. The low utilization of AWVs, despite their marked impact on patients’ engagement with preventive services, indicates that the perceived value of AWVs may be misaligned or that practices cannot effectively integrate them into their office workflow.

Learn more: The Difference Between Annual Physicals and Annual Wellness Visits

How to educate patients on Annual Wellness Visits

Properly educating patients on the purpose of a Medicare AWV is integral to maintaining patient satisfaction and the overall success of the preventive care plan. A patient who is not interested in preventive care is less likely to follow through on the measures proposed by their physician. A patient expecting to talk with their doctor about their chronic illness or medications may be frustrated by the appointment’s emphasis on medical history, lifestyle, and behavioral risk factors. 

Consider using outreach to inform your patients about the purpose and benefits of receiving AWVs. Your practice can distribute mailed material or electronic communication that tells patients what to expect during an AWV and how receiving AWVs can contribute to increased quality of life. These communications can be timed with holidays or patient birthdays or scheduled annually to ensure the patient gets a yearly reminder. 

Additionally, staff members can educate patients about the differences between physicals and AWVs when they come into the office for a routine visit, differentiating the services and offering to schedule the patient for their initial AWV. Combining AWVs with sick or Evaluation and Management (E/M) visits is also a strategic way to maximize the time spent with the patient and the reimbursements available for providing high-quality and thorough care. 

Who is eligible for an Annual Wellness Visit?

Medicare beneficiaries enrolled in Medicare Part B for over 12 months are eligible for Annual Wellness Visits. Patients cannot receive more than one AWV in a 12-month timeframe. Additionally, patients cannot receive an AWV in the same year as their initial Welcome to Medicare preventive visit (also known as an IPPE). Medicare Advantage plans (Medicare Part C) are also required to cover AWVs when a patient visits an in-network provider and meets the eligibility criteria outlined by Medicare.

Patients looking to schedule an AWV with their healthcare provider should ensure they ask for an “Annual Wellness Visit” by name when setting up the appointment. This will help clarify the intention of the appointment and ensure that Medicare fully covers the service.

Multiple healthcare practitioners, including primary care providers, certain specialty providers, and urgent care providers, can administer AWVs. Medicare will only reimburse practices for one AWV per patient per 12-month cycle, so it is crucial to access accurate patient eligibility data before administering the service. 

Some AWV software, like ChartSpan’s RapidAWV, syncs with the HETS (HIPAA Eligibility Transaction System) database, allowing front desk personnel to check Medicare beneficiary data in real time. If they discover a patient is indeed eligible for an AWV, they can easily provide the patient with an HRA to complete within the same application. 

Learn more: How to Identify Eligible Medicare Beneficiaries for Annual Wellness Visits

What is the reimbursement for Medicare Annual Wellness Visits?

Annual Wellness Visits offer between $118-174 in reimbursements per visit. The exact amount will differ based on the details of the individual AWV. The Medicare reimbursements may be increased by pairing them with other relevant preventive services, like smoking cessation consultations, advance care planning, or obesity counseling. These additional services have separate CPT billing codes that may be used with the AWV billing codes to maximize practice revenue* further. 

AWVs are an invaluable asset for any practice, as they can add a streamlined revenue channel while encouraging patients to utilize preventive resources and reduce patient healthcare expenses. 

*Results may vary by provider. 

What are the billing codes for Annual Wellness Visits?

There are three primary CPT codes used to bill AWVs to Medicare:

  • G0402 (Welcome to Medicare / Initial Preventive Physical Exam): The IPPE is a one-time, face-to-face service offered to newly enrolled patients in Medicare Part B and is a precursor to subsequent Annual Wellness Visits. This service is only offered in the initial 12-month window after a patient enrolls and will be rejected after that timeframe elapses.
  • G0438 (Initial Annual Wellness Visit): CPT code G0438 is used to bill for a patient’s first Annual Wellness Visit. If patients complete an IPPE, they are eligible for their initial AWV on the first day of the same calendar month a year later. If they do not take advantage of the IPPE, they are eligible for their first AWV twelve months after enrollment in Medicare. The reimbursement for the initial AWV is higher than subsequent AWVs, so it is critical to correctly bill the service to ensure your practice receives maximum reimbursement for the services rendered. 
  • G0439 (Subsequent Annual Wellness Visits): This billing code is used for every AWV a patient receives after completing their IPPE and initial AWV. They will become eligible for AWVs once every 12 months. This is the only CPT billing code for AWVs that is used more than once.

Apart from the three standard billing codes, multiple codes are relevant to AWVs or often billed in tandem with AWVs. These include: 

  • G0468 (FQHC IPPE or AWV): CPT code G0469 is used by Federally Qualified Health Centers (FQHCs) to bill for visits that include IPPEs or AWVs as part of their bundle of services. Other practices cannot use this code. 
  • 99497 (Advance Care Planning): Advance Care Planning includes discussing and explaining advance directives if a patient becomes debilitatingly ill or otherwise unable to make medical decisions for themselves in the future. When this discussion is provided on the same day as an AWV by the same healthcare provider, it is considered preventive and covered by Medicare. It must be reported with modifier -33 and billed on the same claim as the AWV to waive co-payment. This service can be performed annually. 
  • G0444 (Depression Screening): Depression screenings are often coupled with AWVs and covered by Medicare. They can be performed annually. G0444 cannot be billed with a patient’s initial AWV (CPT code G0438).
  • 99406 and 99407 (Counseling to Prevent Tobacco Use): Medicare covers up to two smoking cessation counseling sessions per patient per year. These are often billed in conjunction with AWVs. 99406 is used for consultations that last between 3 and 10 minutes. Code 99407 is used for consultations that exceed 10 minutes in length. 
  • G0442 and G0443 (Alcohol Misuse Screening & Counseling): G0442 is a screening to detect the risk of alcohol misuse and can be performed once annually. If a patient is identified to be at risk, G0443 is used to bill the subsequent 15-minute behavioral consultation. This service can be performed up to four times per year.
  • G0447 (IBT for Obesity): Patients with a BMI that exceeds 30.0 qualify for obesity consultation services. These can be performed with IPPEs or AWVs and billed up to 22 times in 12 months, depending on the patient’s adherence to the physician’s recommendations and subsequent weight loss. 

Learn more: CPT Billing Codes for Annual Wellness Visits      

Who can perform a Medicare Annual Wellness Visit?

Any of the following practitioners can perform Annual Wellness Visits:

  • A physician (doctor of medicine or osteopathy)
  • A qualified, non-physician practitioner, including a physician assistant (PA), a nurse practitioner (NP), or a certified clinical nurse specialist (CCNS)
  • A medical professional like a registered dietitian, nutrition professional, or health educator, or a team of medical professionals directly supervised by a physician or another licensed healthcare practitioner

It is integral to remember that AWVs can be performed and billed by practices other than primary care facilities. Specialists like cardiologists or neurologists may also submit claims for AWV reimbursement. CMS has intentionally sought to reduce barriers to administering AWVs and HRAs to facilitate greater use and easier workflow implementation. 

However, without eligibility verification, this can lead to multiple practices attempting to bill Medicare for the same service and risks patients receiving poorly optimized, duplicated care. Medicare will only reimburse one AWV per patient within a 12-month timeframe. This is why checking patient eligibility in real-time is crucial before practice resources and patient time are devoted to redundant and non-reimbursable services.   

Implement AWVs into your workflow easily with ChartSpan’s RapidAWV™ software

The challenge: Only 19% of eligible Medicare patients receive AWVs. When properly implemented into a practice’s workflow, AWVs have the dual benefit of creating an additional revenue stream and facilitating positive patient clinical outcomes by encouraging targeted preventive care. However, many physicians view AWVs as overly time-consuming, staff may struggle to confirm patient eligibility, and many patients do not see the value in an appointment that does not address their current conditions, medications, and physical health. 

Our solution: ChartSpan’s proprietary RapidAWV™ software provides healthcare providers with an innovative solution to maximize revenue while significantly minimizing the time and resources required to implement AWVs. 

Real-time eligibility checks

When patients arrive for their scheduled sick visit, clinical staff can use the RapidAWV™ program to check their AWV eligibility via CMS’s HETS database in real time. If the patient is determined eligible for an AWV, your clinical staff can provide an HRA for the patient to complete on a desktop, tablet, or mobile device. These customizable, senior-friendly questionnaires are iOS and Android compatible and optimized for access across any device and screen size. 

Accessible and customizable HRAs

The patient can complete their HRA from the comfort of your practice’s waiting room while they await their regularly scheduled appointment, seamlessly integrating the AWV into their pre-existing appointment without causing any disruption to standard practice workflow

These HRAs can be customized by the practice to include questions about medical history, lifestyle, risk factors, and whatever additional information you wish to gather. Upon completion, the software will then deliver a comprehensive, robust report to the attending physician, outlining risk factors and recommended screenings and flagging pertinent factors like nutrition, tobacco use, medication adherence, and vaccinations. 

Personalized preventive care plans

By analyzing the data provided by patients, ChartSpan’s AWV software generates 5- to 10-year preventive care plans with actionable goals, deliberate interventions, and timely follow-ups. It also gives patients clear summaries of their health risks and preventive care plans. 

This automated, data-driven AWV technology dramatically reduces the time required to administer an AWV. This ensures an AWV can be neatly combined with the scheduled appointment yet still deliver a tailor-made preventive care program for the individual patient. 

Partner with ChartSpan to maximize AWVs

With the ease of ChartSpan’s RapidAWV™ software, physicians at your practice can incorporate AWVs into any previously scheduled patient sick visit. Any inconvenience to the patient is minimized by attaching the AWV to a pre-existing appointment, encouraging higher participation. 

Our software checks eligibility instantly, eliminating the risk of your practice providing a non-reimbursable service. Furthermore, the software collects, analyzes, and synthesizes the information provided by the patient into an actionable preventive care plan unique to them, allowing you to maximize every appointment and elevate the quality and scope of care your practice provides. 

To ensure your team’s success with RapidAWV™, ChartSpan provides comprehensive onsite or remote training in our software and a dedicated Client Success Director to help your AWV enterprise flourish. 

Contact us to learn how ChartSpan can elevate your practice’s care delivery and operational excellence with our industry-leading AWV software.     

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