Prepare for Proper Preventive Service Coding
Learn the differences between preventive visits and Medicare Wellness Visits (MWVs), including coding, screenings, and key components for accurate billing and documentation.
PCP Medical Billing & Coding Alert
Review the requirements for Medicare Wellness Visits (MWVs) and Annual Wellness Visits (AWVs)
In Primary Care Coding Alert Volume 26 Number 7, we discovered valuable insights on preventive coding for children. This issue explores the differences between adult preventive visits and Medicare Wellness Visits (MWVs).
Continue reading for important information about these distinctions as explained by Christine Hall, CHC, CDEO, CPC, CPB, CPMA, CRC, CEMC, CPC-I, CEO and senior consultant at Stirling Global Solutions LLC, in her HEALTHCON 2024 presentation titled “An Ounce of Prevention is Worth a Pound of Cure.” You will also find several common screenings that may apply to both types of visits.
Purpose of Under-65 Preventive Visits
These visits include an exam that is not connected to the treatment or diagnosis of a specific illness, symptom, complaint, or injury and may involve laboratory and diagnostic procedures. They are generally covered by commercial payers, Medicaid, and many Medicare Advantage plans. Billing for these visits depends on whether the patient is new or established and on their age.
Use codes 99381
Use codes 99381 (Initial comprehensive preventive medicine evaluation and management of an individual, including age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and ordering of laboratory/diagnostic procedures, new patient; infant under 1 year) through 99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual, including age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and ordering of laboratory/diagnostic procedures, established patient; age 65 and older) for preventive visit coding.
How does it Differs from the Purpose of Medicare Wellness Visits?
These visits are designed to prevent disease and disability by addressing future medical issues based on the beneficiary’s health status and risk factors, using various tools like health risk assessments. Both Medicare and Medicare Advantage cover these plans, and at least one code is billed based on the Medicare Part B effective date.
Coding for Medicare Wellness Visits
To code Medicare wellness visits, use the following codes:
- G0402: Initial preventive physical examination; face-to-face visit, limited to new beneficiaries during the first 12 months of Medicare enrollment.
- G0438: Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit.
- G0439: Annual wellness visit, subsequent visit.
Understanding “Medicare Wellness Visit” (MWV) Terminology
In clinical and coding environments, the term "Medicare Wellness Visit" (MWV) is widely used but actually encompasses three specific types of visits as defined by the Centers for Medicare & Medicaid Services (CMS). While MWV is often referenced as a single type of exam, CMS includes several services under this term: the "Welcome to Medicare Visit" or Initial Preventive Physical Exam (IPPE) (code G0402), the Annual Wellness Visit (AWV) — both initial (G0438) and subsequent (G0439) — and routine physical exams. This classification is detailed in the MLN release “Medicare Wellness Visits.”
Audit Priority for IPPEs and AWVs
IPPEs and AWVs are frequently audited due to Medicare’s complex billing requirements. They are priority review items for Recovery Audit Contractors (RACs), Targeted Probe and Educate (TPE) reviewers, and Comprehensive Error Rate Testing (CERT) auditors.
Understanding the Role of the Physical Exam
Patients—and often coders—may not fully grasp the distinctions between standard adult preventive services and the Medicare Wellness Visit (MWV) or Annual Wellness Visit (AWV). Many assume that annual visits always include a physical exam, leading to confusion when an exam is either not conducted or not covered by insurance. Below is a summary of how physical exams factor into each type of visit.
Preventive Visit
For adults, a preventive physical exam is an age- and gender-appropriate comprehensive evaluation of overall health. The provider assesses the patient's general health, identifies any potential health issues, and offers anticipatory guidance, medical advice, counseling, or risk reduction strategies.
Medicare Wellness Visit (MWV) / Annual Wellness Visit (AWV)
The Initial Preventive Physical Exam (IPPE) is a physical exam covered by Medicare, but it’s the only preventive physical exam available for traditional Medicare beneficiaries upon entering the program. "Within that first 12 months, we need to get a good picture of what the patient looks like," explained Hall. After the first year, however, beneficiaries are eligible for an AWV, which does not include a physical exam. "After that first year, they’re eligible for an initial annual wellness visit, not a physical exam," Hall noted.
Key Components of the Medicare Wellness Visit (MWV) and Annual Wellness Visit (AWV)
Providers must complete and document specific components to bill for MWVs, with most requirements being similar for both the Initial Preventive Physical Exam (IPPE) and AWV, though some are described differently. Essential components include:
- Medical and Social History Review: Assessment of the patient’s medical and social background.
- Risk Factor Evaluation for Mood Disorders: Screening for potential depression and other mood disorders.
- Functional Ability and Safety Assessment: Evaluating the patient's ability to perform daily activities, risk of falls, and home safety.
- Vital Signs Measurement: Recording blood pressure, height, weight, and BMI (or waist circumference if applicable). The IPPE also requires a visual acuity screening.
- Opioid Prescription Review: Evaluation of current opioid prescriptions.
- Substance Use Disorder Screening: Screening for potential substance use disorders.
- Personalized Prevention Plan: Development of a prevention plan, including a written schedule and referrals for appropriate preventive services, such as screenings and immunizations.
- Risk Factor and Condition List: Identification of conditions needing primary, secondary, or tertiary intervention.
- Advance Care Planning Documentation: Recording the patient’s advance care planning status or providing resources to assist with advance care planning based on the patient’s preferences.
Additional Components Included in Annual Wellness Visits (AWVs)
In addition to the standard components, Annual Wellness Visits (AWVs) include up to four additional elements:
- Health Risk Assessment (HRA): Conducting an HRA to gather comprehensive health and lifestyle information.
- Provider and Supplier List: Establishing a list of the patient's current healthcare providers and suppliers.
- Cognitive Impairment Detection: Screening for any cognitive impairments the patient may have.
- Social Determinants of Health Risk Assessment: Performing an optional assessment of social determinants of health, a new component introduced in 2024.
Preventive Medicine and MWV/AWV Service Overlap: Key Screenings and Tests
Certain screenings and tests are applicable to both adults under and over age 65, with specific codes assigned to each. These are some common screenings that overlap across preventive medicine and Medicare Wellness Visit (MWV)/Annual Wellness Visit (AWV) services:
Alcohol Misuse Screening and Counseling
- 99408: Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes.
- 99409: Same as 99408, but for services greater than 30 minutes.
- G0442: Annual alcohol misuse screening, 5 to 15 minutes.
- G0443: Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes.
Depression Screening
- 96127: Brief emotional/behavioral assessment (e.g., depression inventory, ADHD scale), with scoring and documentation, per standardized instrument.
- G0444: Annual depression screening, 5 to 15 minutes.
Diabetes Screening
- 82947: Glucose; quantitative, blood (excluding reagent strip).
- 82950: Glucose; post-glucose dose (includes glucose).
- 82951: Glucose tolerance test (GTT), 3 specimens (including glucose).
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