A Medicare Annual Wellness Visit (AWV) is a preventive screening used to identify gaps in care.
As covered by Medicare Part B, providers should understand what CPT billing codes matter to the service and how to use them. This can help your organization avoid denied claims and enhance care.
AWVs are covered for Medicare Part B patients without a co-pay. This yearly assessment helps patients create personalized care plans that providers can use to improve outcomes.
AWVs are reimbursable under Medicare’s Physician Fee Schedule, paying various rates.
Different CPT billing codes reflect specific types of Medicare wellness visits. The crucial qualifying determinant is when a certain AWV can be provided and billed for.
There are three types of wellness visits: Initial Preventive Physical Examination (IPPE), an Initial Annual Wellness Visit, and the Subsequent Annual Wellness Visit. Each entails a different billing code as well as specific qualifiers for each program.
Medicare’s wellness visit is a yearly assessment of a patient’s health used to identify risks and create a personalized care plan. AWVs are different from yearly physical examinations. They offer a more complete review of a patient’s medical history and current lifestyle to suggest care goals that close gaps.
Wellness visits can be of particular importance for patients living with chronic conditions.
With an AWV, a personalized care plan is designed to help manage chronic illnesses, as well as schedule preventive screenings to improve early detection of disease.
AWV billing must be directed by a provider with an NPI number. However, clinical staff can administer most of the assessment, saving physician time and involvement. Eligible providers include:
The following components must be included in a patient’s wellness visit:
Five items are required when submitting a Medicare claim:
It is helpful to know the staff care coordinator assigned to a patient in case of an audit.
AWVs ask about lifestyle, social history, mental health and home environment. Documenting these details can help providers risk-stratify patient populations and develop comprehensive, personalized care plans that can close gaps.
This can help clinicians better coordinate services, streamline collaborative decision-making and support value-based care delivery. AWVs have been shown to build stronger provider-patient relationships, secure additional revenue and contribute to cost savings.
Medicare supports additional CPT codes for optional, add-on services related to AWVs. These include Advance Care Planning and a social determinants of health screening.
Advance Care Planning helps patients prepare for future medical decision-making in case of serious illness or they are unable to communicate their care preferences. Specifically, Advance Care Planning includes two primary documents:
An AWV assessment asks patients whether they have Advance Care Planning documents in place. If not, the provider can use the AWV to discuss advance care options and schedule time to complete a plan.
The average billing rate is $79.57. To accurately bill for code 99497, services must:
Documentation to account for at least 16 minutes of service time should record that the ACP conversation was voluntary on behalf of the patient, encapsulate what was talked about, record who was present for the conversation, and note the length of time for the consultation.
Again, it is not required to complete an advance care directive during ACP. Completion is only required if you’ve noted in your documentation that you’ve performed this task. However, when ACP is completed with an AWV, it is entirely covered for the patient.
This is simply an add-on billing code to allow for an additional 30 minutes of ACP services. The average reimbursement rate is $68.90. Requirements for billing this code include:
Providers can collect social determinants of health (SDOH) data while performing an AWV. SDOH discussions should be between 5 and 15 minutes in length, and cover food and housing insecurities, transportation needs, and utility difficulties.
The SDOH risk assessment addresses factors that influence the diagnosis and treatment of patients’ medical conditions. While not designed as a screening, the assessment is tied to one or more known or suspected SDOH needs.
Providers can receive an additional $18.44 for assessing SDOH during an AWV. For the patient, this assessment is fully covered by Medicare when provided with an AWV.
To claim this CPT code, providers must:
Medicare stresses the importance of following up with patients about SDOH and working to connect them with available resources.
Federally Qualified Health Centers (FQHC) can bill for AWVs, but they utilize additional codes.
In addition to the standard CPT codes associated with AWVs, an FQHC may use a special add-on code (G0468) that will support additional reimbursement.
For example, if an FQHC were to provide an Initial Preventive Physical Examination, the clinic would bill for G0402 + G0468. This coding indicates to Medicare that the service is being provided through an FQHC.
These organizations receive much higher average reimbursement rates.
Annual Wellness Visits can help enroll patients in care management programs, or provide additional assessments.
While there can be confusion around this opportunity, AWVs can be billed concurrently with problem visits, just not under the same code. Also, there are add-on services that can be billed concurrently, including:
CMS also allows clinicians to enroll patients in Medicare care management programs during the AWV if they are eligible. The AWV is a great time to invite a patient into a care management program. It provides an invaluable service that supports a patient in realizing personalized health goals that align with the issues and risks discussed during the AWV.
Care management programs give the care plan structure, cadence and substance, making it actionable.
The table below outlines the general eligibility requirements for patients to join each of the Medicare care management programs. This matrix can help highlight which programs may fit your patient populations, indicating those programs you should consider offering during the AWV.
To maximize the value of the AWV and enhance enrollment into care management programs, it helps to map out a workflow that indicates how you will engage patients before, during and after the yearly visit.
ThoroughCare gives providers the tools and support to make Annual Wellness Visits effective.
We help providers, based on their specific needs, build AWV programs or scale existing services. ThoroughCare supports a comprehensive software platform, clinical expertise to optimize workflows and assistance with data and reporting for quality improvement.
ThoroughCare includes digital solutions, such as:
*Reimbursement rates are based on a national average and may vary depending on your location.
Check the Physician Fee Schedule for the latest information.