Annual Visit Codes, Their Dates and Ages

Annual Wellness Visit Cpt Code are vital in preventive healthcare, ensuring patients receive age-appropriate screenings and wellness exams. Medicare offers specific coverage for preventive services, including the Initial Preventive Physical Exam (IPPE) for new beneficiaries within their first 12 months of Part B coverage and Annual Wellness Visits (AWVs) for ongoing preventive care every 12 months. However, routine physical exams, which are not tied to a specific diagnosis or treatment, are not covered by Medicare and require out-of-pocket payment. Understanding the correct visit codes, eligibility criteria, and patient responsibilities helps ensure accurate billing and clear communication between providers and patients.

Understanding Medicare Physical Exam Coverage and Annual Visit Codes

Medicare offers various preventive services to ensure beneficiaries receive essential health screenings and wellness check-ups. However, it is important to understand the differences between Initial Preventive Physical Exams (IPPEs), Annual Wellness Visits (AWVs), and Routine Physical Exams to ensure accurate billing and patient education. Below is a breakdown of each service and its coverage details.

• IPPE is a one-time Welcome to Medicare exam covered within the first 12 months of Part B enrollment.
• AWV is an annual Medicare-covered visit that focuses on risk assessment and preventive care, without a full physical exam.
• Medicare does not cover Routine Physicals, and patients must pay out-of-pocket.

Let’s explore this in detail:

Understanding the Initial Preventive Physical Exam (IPPE)

The Initial Preventive Physical Exam (IPPE), commonly called the “Welcome to Medicare” visit, is a one-time preventive service designed to promote early disease detection and overall wellness. Medicare covers this exam only within the first 12 months of a patient’s Part B enrollment, ensuring new beneficiaries receive essential health assessments and preventive guidance at no cost (if the provider accepts the assignment).

Key Components of the IPPE

1. Medical & Social History Review – To assess health risks, patients provide details about their past illnesses, surgeries, medications, family history, diet, physical activity, and substance use.
2. Depression & Mood Screening – Providers evaluate mental health using standardized screening tools to identify risk factors for depression or mood disorders.
3. Functional & Safety Assessment includes screening for fall risk, hearing issues, daily activity limitations, and home safety concerns to ensure overall well-being.
4. Physical Exam – Basic health metrics such as height, weight, BMI, blood pressure, and vision screening are recorded to establish a baseline for future care.
5. End-of-Life Planning (Optional) – Patients can receive information on advance directives for future healthcare decisions.
6. Opioid & Substance Use Review – If applicable, providers assess opioid prescriptions, pain management options, and substance use disorder (SUD) risks, offering referrals when needed.
7. Preventive Education & Counseling – Patients receive guidance on additional preventive screenings, vaccinations, and wellness strategies tailored to their health status.

Billing & Coding for IPPE

Medicare requires specific HCPCS codes to file IPPE claims:

• G0402 – Initial preventive physical examination; face-to-face visit, services limited to new beneficiaries during the first 12 months of Medicare enrollment
• G0403–G0405 – Screening electrocardiogram (ECG) for IPPE
• G0468 – Federally qualified health center (FQHC) visit, ippe or awv; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit CPT code (AWV) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV

Providers may also bill for medically necessary evaluation and management (E/M) services conducted during the IPPE using CPT codes 99202–99205 or 99211–99215, with modifier 25 indicating a separate service.

The IPPE is a crucial first step in a Medicare patient’s preventive care journey. It helps identify risks early and connects them with necessary healthcare services.

Annual Wellness Visit & Health Risk Assessment

The Annual Wellness Visit (AWV) is a preventive healthcare service designed to evaluate a patient’s well-being and identify potential health risks. A key component of this visit is the Health Risk Assessment (HRA), which helps healthcare providers create personalized prevention plans. 

Below is a detailed breakdown of the key elements of an AWV and HRA, including the latest updates.

First Annual Wellness Visit Components

Conduct a Health Risk Assessment (HRA)

The HRA is a questionnaire used to collect self-reported patient information. It can be completed before or during the visit and should be structured to accommodate diverse populations, including those with low health literacy, language barriers, and disabilities.

The assessment includes the following key elements:

• Demographic Data – Basic personal information such as age, gender, and contact details.
• Self-Assessment of Health Status – Patient’s general health and well-being perception.
• Psychosocial Risks – Factors like depression, stress, loneliness, fatigue, and chronic pain.
• Behavioral Risks – Smoking, alcohol use, physical activity levels, oral health, and home safety.
• Activities of Daily Living (ADLs) – Basic self-care abilities, such as dressing, bathing, and mobility.
• Instrumental ADLs (IADLs) – More complex tasks like managing medications, shopping, and finances.

Review Medical & Family History

A thorough medical and family history review helps understand genetic predispositions and past health conditions. Providers should document:

• Significant medical events in the patient’s immediate family.
• Past medical conditions, surgeries, allergies, and treatments.
• Current medications, vitamins, and supplements.

Identify Current Healthcare Providers & Suppliers

Patients may have multiple healthcare providers managing different aspects of their health. During the AWV, the provider should:

• Compile a list of all primary care and specialty providers involved in the patient’s care.
• Document any behavioral health providers, home health agencies, or medical equipment suppliers.

Conduct Basic Health Measurements

Tracking health metrics over time helps identify early signs of chronic diseases. The AWV should include:

• Height, weight, and Body Mass Index (BMI)
• Blood pressure measurement
• Waist circumference (if applicable)

Evaluate Cognitive Function

Cognitive impairment screening is essential to the AWV, especially for older adults. Providers should:

• Observe for memory issues, confusion, or disorientation.
• Use standardized tests for early detection of Alzheimer’s or dementia.
• Consider input from family members or caregivers.

Assess Depression & Mood Disorders

Mental health is a critical aspect of overall well-being. Providers should:

• Screen for depression, anxiety, and other mood disorders using validated tools.
• Identify past mental health conditions and current symptoms.
• Refer patients for counseling, therapy, or psychiatric evaluation if needed.

For standardized screening tools, visit the American Psychiatric Association’s Depression Assessment Instruments.

Evaluate Functional Ability & Safety

Assessing functional status helps determine if a patient needs supportive services. Providers should evaluate:

• Activities of Daily Living (ADLs) – Self-care tasks like eating, bathing, and dressing.
• Fall risks – Mobility issues, dizziness, or balance problems.
• Hearing and vision impairments – Sensory deficits that impact daily life.
• Home safety – Risks related to living alone, medication mismanagement, and driving ability.

Develop a Preventive Screening Schedule

A 5–10 year preventive care plan should be created based on:

• USPSTF (U.S. Preventive Services Task Force) & ACIP (Advisory Committee on Immunization Practices) guidelines.
• The patient’s health risks and current conditions.
• Recommended screenings for cancer, diabetes, osteoporosis, and other chronic diseases.

Identify Risk Factors & Conditions

Providers should compile a list of risk factors and conditions requiring intervention. These may include:

• Chronic illnesses like diabetes, hypertension, or heart disease.
• Mental health concerns such as anxiety or substance use.
• Preventive screenings and lifestyle modifications are needed for better health.

Provide Personalized Health Advice & Referrals

Tailored health counseling can improve long-term well-being. Providers should:

• Offer guidance on fall prevention, nutrition, exercise, and weight management.
• Refer patients to smoking cessation, mental health, and chronic disease management programs.
• Discuss social engagement and cognitive health support options.

Discuss Advance Care Planning (ACP) (Optional)

Advance Care Planning (ACP) allows patients to make future healthcare decisions. Discussions may include:

• Creating an Advance Directive (e.g., living will, power of attorney).
• Identifying a healthcare proxy or caregiver.
• Discussing end-of-life care preferences.

Review Opioid Prescriptions (If applicable)

For patients using opioids for chronic pain, providers should:

• Assess pain levels and effectiveness of current treatment.
• Discuss alternative pain management options.
• Identify signs of opioid dependence or misuse.

Screen for Substance Use Disorders (SUDs)

Providers should evaluate risk factors for substance use disorders (SUDs), particularly for:

• Alcohol, prescription medications, and illicit drug use.
• Mental health conditions that may contribute to substance misuse.
• Referral to addiction specialists or rehabilitation programs if necessary.

For screening tools, visit the National Institute on Drug Abuse (NIDA) website.

Address Social Determinants of Health (SDOH) (New for 2024)

Medicare now includes an optional SDOH Risk Assessment to evaluate housing, financial security, and access to healthcare services.

Subsequent Annual Wellness Visits (AWVs)

Follow-up AWVs involve updating previous assessments and ensuring continued preventive care.

Key Updates Include

• Revising the Health Risk Assessment (HRA)
• Updating medical & family history
• Assessing new healthcare providers
• Rechecking weight, blood pressure, and health measurements
• Continuing cognitive, mood, and functional ability screenings
• Modifying the preventive screening schedule
• Adjusting personalized health advice
• Reevaluating opioid use and substance abuse risks

 

AWV Coding, Diagnosis, and Billing

HCPCS Codes for AWV Claims

• G0438 – Initial Annual Wellness Visit (AWV) including a Personalized Prevention Plan of Service (PPS).
• G0439 – Subsequent AWV including a Personalized Prevention Plan of Service (PPS).
• G0468 – Federally Qualified Health Center (FQHC) visit, covering an Initial Preventive Physical Examination (IPPE) or AWV, bundled with Medicare-covered services per diem.
  • Refer to Section 60.2 of the Medicare Claims Processing Manual, Chapter 9, for billing guidelines.

Diagnosis Code Requirements

• A diagnosis code is required when submitting AWV claims.
• Medicare does not mandate a specific AWV diagnosis code; choose any appropriate code consistent with the patient’s exam.

Billing Guidelines

• Eligible Providers:
  • Physicians (MDs or DOs)
  • Qualified Non-Physician Practitioners (PAs, NPs, CNSs)
  • Medical Professionals under direct physician supervision (e.g., health educators, registered dietitians, nutritionists, or other licensed practitioners)
• Additional Services:
  • If an AWV includes a significant, separately identifiable Evaluation & Management (E/M) service, Medicare may reimburse for the additional service.
  • Report additional E/M services using CPT codes 99202–99205 and 99211–99215 with modifier 25.
• Billing Restrictions:
  • G0438 is billed only once per lifetime for an initial AWV.
  • G0439 is billed only once every 12 months for subsequent AWVs.
  • Avoid billing G0438 or G0439 within 12 months of a G0402 (IPPE) claim.
  • Medicare denies claims exceeding the allowed frequency.
• Telehealth:
  • HCPCS codes G0438 and G0439 are covered under Medicare telehealth services.

Advance Care Planning (ACP) – Optional AWV Element

• Definition:
  • ACP is a face-to-face discussion between providers and patients regarding medical treatment preferences and advance directives.
  • ACP can be included as part of an AWV at the patient’s discretion.

CPT Codes for ACP Claims

• 99497 – Advance care planning, including explaining and discussing advance directives (first 30 minutes, face-to-face).
• 99498 – Additional 30 minutes of advance care planning (billed separately with 99497).

Billing Guidelines

• Coinsurance & Deductible Waiver:
  • Waived when ACP is billed on the same day as an AWV by the same provider.
  • Use modifier 33 (Preventive Service) to qualify for a waiver.
  • Medicare applies coinsurance and deductible if ACP is billed outside of an AWV.
• Frequency:
  • No set limits on how often ACP can be billed per patient.
  • Multiple billings require documentation of changes in the patient’s health status or end-of-life care preferences.

Social Determinants of Health (SDOH) Risk Assessment – Optional AWV Element

• Definition:
  • An assessment evaluating social factors affecting a patient’s health guides medical decisions and treatment plans.
  • Available as an optional component of the AWV.

HCPCS Code for SDOH Risk Assessment

• G0136 – Administration of a standardized, evidence-based SDOH risk assessment tool (5-15 minutes).

Billing Guidelines

• Coinsurance & Deductible Waiver:
  • Waived when billed on the same day as an AWV by the same provider.
  • Use modifier 33 (Preventive Service) to qualify for a waiver.
  • Medicare applies the deductible and coinsurance if the AWV claim is denied for exceeding the annual limit.
• Frequency:
  • SDOH Risk Assessment deductible and coinsurance are waived once per year when billed with an AWV.
  • If performed separately from the AWV, standard cost-sharing applies.

 

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FAQs

Is the Annual Wellness Visit (AWV) the same as a yearly physical?

No, the AWV is not a traditional physical exam. It focuses on preventive care, risk assessment, and personalized health planning rather than a hands-on physical examination.

Does the deductible, coinsurance, or copayment apply to the AWV?

No, Medicare covers the AWV at 100% when performed by a participating provider. However, cost-sharing may apply if additional services are provided during the visit.

Who is eligible for the AWV?

Medicare beneficiaries who have had Part B coverage for over 12 months and have not received an IPPE or AWV within the past year are eligible.

Are clinical lab tests part of the IPPE or AWV?

No, neither the IPPE nor the AWV includes laboratory tests. However, necessary tests may be ordered separately, and coverage depends on Medicare guidelines.

Can an AWV and an electrocardiogram (EKG) be billed on the same service date?

Yes, an AWV and an EKG can be billed on the same date, but the EKG is not covered as part of the AWV and may be subject to cost-sharing.

How do I determine if a patient has already received their first AWV from another provider?

You can check the Medicare Administrative Contractor (MAC) portal or contact Medicare to verify the patient’s AWV history before billing for a subsequent AWV.

Is the Initial Preventive Physical Examination (IPPE) the same as a yearly physical?

No, the IPPE is a one-time preventive visit for new Medicare beneficiaries. It focuses on health screening, risk assessment, and education rather than a comprehensive physical exam.

Does the deductible, coinsurance, or copayment apply to the IPPE?

No, Medicare covers the IPPE at 100%, provided it is performed within the first 12 months of Part B enrollment. However, additional services may result in cost-sharing.