Reimbursement rates for Annual Wellness Visits (AWV) are tied to the program’s Current Procedural Terminology (CPT) codes. These codes help categorize and specify billing rules and requirements for the procedures, treatments, and care services related to AWVs.
As a provider, you may have an interest in starting an AWV program. The service can be of great benefit to your patients by helping them assess their health and plan for future care needs. Wellness visits also have the potential to help your practice implement value-based care.
The service can help address certain performance metrics, such as patient engagement and clinical efficiency. These indicators can ultimately influence revenue expectations under various value-based care payment models.
Understanding AWV’s billing codes can help your organization further assess whether this program is a good investment of resources. Wellness visits, like other care management programs, can generate revenue for practices.
That said, without an example to look at or working knowledge of reimbursement rates, it might be hard to understand the potential benefits of offering AWVs at your practice. Knowing the CPT codes for AWV can help your practice project revenue and optimize your care team’s capacity.
At ThoroughCare, we’ve worked with clinics and physician practices across the U.S. to help them streamline and capture Medicare reimbursements. Our care coordination software assists with AWV’s rules and regulations, and it tracks all activities related to providing the program, making it easier to bill for.
In this article, and the video just below, we’ll cover reimbursement rates for the three types of AWVs that you can provide. We’ll also review how the program can deliver a return on investment (ROI) for providers and patients.
Initial Preventive Physical Examination (IPPE). Your patients may only receive this benefit within the first 12 months of their Medicare enrollment. After the initial eligibility period, your patient cannot receive an IPPE. It is also dependent on a health risk assessment (HRA).
Initial Annual Wellness Visit. This is practically identical to an IPPE, except it is available to your patient only after 12 months of Medicare enrollment. It is for patients that miss their window for an IPPE. However, if your patient does complete an IPPE, they must still complete the IAWV. An HRA drives the IAWV process, as well. But this screening also includes an optional cognitive exam and “end-of-life” planning.
Subsequent Annual Wellness Visit. This is the yearly follow-up to an IAWV. Eleven months after an IAWV, a patient can attend these sessions to modify and maintain their preventive care plan, based on how their health is at any given time.
Each iteration of AWV has its own associated CPT billing code. The graphic below highlights each reimbursement rate. Additionally, Advance Care Planning (ACP) is an add-on service that can help your patients with end-of-life planning. This supports its own CPT code.
Billing AWV: An ROI Example of Revenue Generation
Let’s look at the revenue potential of an annual wellness program. With the ROI example shown below, we'll look at a single practice that's billing for SAWVs along with ACP.
Using CPT Code G0439 for AWV and CPT Code 99497 for ACP
A subsequent AWV is accounted for by CPT code G0439. The national average reimbursement rate for billing this is $130.13 per month. For ACP, the average rate is $83.02 with CPT code 99497.
Assuming you’ve helped 500 patients complete an AWV in a year, you could expect to generate about $65,065 in reimbursement, annually. If half of these patients (250) completed ACP, your practice could net an additional $20,755 per year. In total, you could see $85,820 in new revenue.
This figure does not account for staff wages, such as a care manager, who will likely help administer the program. That said, it’s possible that you’re already performing some of the activities related to AWV, as your patients receive an annual physical or consultation. By formally implementing and billing for the program, you can capture reimbursement for services that you may usually provide.
Additional AWV Benefits for You and Your Patients
While the phrase return on investment (ROI) holds a financial connotation, a “return” isn’t entirely dependent on monetary value. General benefits are equally important, especially with regard to patient health and outcomes.
Additionally, an AWV program can boost clinical efficiency.
The outcome of an annual assessment is the creation of a customized patient-centered care plan. This document can help you further personalize the patient’s experience as you interact with them over time. This can reduce the need to repeat conversations with the patient, as well as promote better coordination between providers and specialists.
Automation with the help of software solutions can also streamline the AWV process, saving you time with paperwork and ensuring proper billing codes are utilized. This can allow you to place more focus on the actual patient and make the most of your time with them.
Digital care coordination tools can help your practice implement and scale your AWV program. A software solution can help automate administrative tasks, track billable time, and report patient data. This can help you maximize reimbursement opportunities, increase clinical efficiency, and address value-based care metrics.