What’s Not Covered in a Medicare Annual Wellness Visit?

Annual Wellness Visits (AWVs) have been shown to reduce healthcare expenses by 5.7% for Medicare beneficiaries. In addition to reducing future costs, AWVs provide an opportunity to assess a patient’s health risks and create a personalized prevention plan.

Because the AWV is intentionally proactive, it focuses on preventive care and long-term patient health. It sets a plan of care for avoiding disease, comorbidities and disability. 

However, it’s critical to understand what is and isn’t covered in a Medicare AWV. This ensures accurate reimbursement and minimizes the risk of claim denials. 

What is reimbursable during an Annual Wellness Visit?

During the AWV, patients receive a comprehensive health risk assessment (HRA) and personalized prevention plan. These cover a host of potential health and social issues, including:

• Establishing the patient’s risk factors, including family health history
• Reviewing age-appropriate preventive screenings
• Measuring height, weight, blood pressure and other routine metrics
• Providing optional Advance Care Planning services 
• Reviewing current medications, including opioid prescriptions
• Screening for potential mental health conditions  and cognitive impairment
• Conducting an optional Social Determinants of Health (SDOH) Risk Assessment 

AWVs can be performed by:

• Physicians
• Qualified non-physician practitioners, such as nurse practitioners, physician assistants or certified clinical nurse specialists
• Medical professionals, including health educators, registered dietitians, nutrition professionals or other licensed practitioners or a team of medical professionals providing services under the direct supervision of a physician

There are three types of AWVs:

• Initial Preventive Physical Examination (IPPE): This “Welcome to Medicare” appointment is a one-time benefit available to patients within the first 12 months after their Part B coverage begins
• Initial Annual Wellness Visit: Available 12 months after completing an IPPE or, if an IPPE was not completed, 12 months after enrolling in Medicare Part B 
• Subsequent Annual Wellness Visit: Available annually, 12 months after the last AWV

What CMS does not cover

Patients often confuse an AWV with an annual physical. It is important for clinicians and office staff to help patients understand the differences between these visits, including which services are covered by Medicare and which are not.   

The three types of Medicare Annual Wellness Visits do not reimburse for the diagnosis or treatment of current or new medical conditions or symptoms. CMS does not cover the following as part of the AWV:

• Detailed physical examinations
• Diagnosis or discussion of current or new medical symptoms, illnesses or conditions 
• Treatment for new or existing chronic or acute illnesses
• Adjustments or changes to medication prescriptions
• Administering vaccinations
• Diagnostics like bloodwork, lab tests or x-rays

These services focus on diagnosing and treating current or new medical symptoms or diseases. They would be billed as a regular provider visit. And, while an AWV may be combined with a regular visit, patients and staff must understand how the two aspects of care are documented, billed and reimbursed separately.

Despite the challenges of promoting the value and limitations of an Annual Wellness Visit, adding or expanding this program provides three essential benefits to the patient, the physician and the practice.

Three reasons to start or grow an AWV program

The Annual Wellness Visit can act as a gateway toward better health outcomes. It can introduce specific service add-ons and offer an opportunity to enroll patients in care management programs. 

1. AWVs support preventive care and health maintenance

Despite studies that link AWV participation to improved preventive care, cost savings and revenue generation, only 24 percent of eligible beneficiaries receive them. Increasing AWV completion rates can not only close care gaps based on evidence-based standards but also support improved quality metrics and provider performance.

Optimizing an AWV program helps patients make the connection between activities like screenings, assessments and vaccinations. They can also improve the prevention and early detection of cancers and other diseases.

2. AWVs offer a new revenue stream

Annual Wellness Visits can generate new and needed revenue. They can also connect patients to services through a personalized prevention plan.  

In one illustration we presented in a previous blog, AWVs and complementary services could generate more than $80,000 in new revenue. The example considered 500 Medicare patients receiving an AWV each year, with half also receiving Advance Care Planning services. 

Additionally, CMS allows concurrent billing for certain add-on services that support preventive care, including:

• Advance Care Planning (CPT codes 99497 and 99498)
• Depression screening (CPT code G0444 – not permitted with the initial AWV)
• Smoking cessation counseling (CPT codes 99406 and 99407)
• Obesity counseling (CPT code G0447) 
• Substance use disorder screening and counseling (CPT codes G0442 and G0443)

3. AWVs provide care management enrollment opportunities

Clinicians may use the AWV to identify patients eligible for Medicare care management programs.

Eligible patients can leave the AWV with an  updated personalized prevention plan, along with information about programs designed to provide further support in managing their health. 

ThoroughCare enables care management enrollment 

At ThoroughCare, we’ve worked with clinics and physician practices across the US to help them streamline and capture Medicare reimbursements. Our care coordination software offers a simple workflow for Annual Wellness Visits, assisting with CMS rules, tracking activities and making billing easier. 

Through the following features, ThoroughCare simplifies the AWV process so providers can focus on engaging patients:

• Interactive health risk assessment
• Screening tools, such as ADL, CAGE, DAST-10, GAD-7, MDQ, PAC, PHQ-2, and a mini cognitive exam
• Care gaps summary with recommended interventions
• Personalized prevention plan
• Seamless enrollment in care management programs
• Automated CPT code assignment for accurate billing

With ThoroughCare, every care management program is available without activation. Simply enroll a patient, and that platform module will become active. 

Key questions answered

What is covered in a Medicare Annual Wellness Visit?

During each of the three types of Annual Wellness Visits, patients receive a comprehensive health risk assessment and personalized prevention plan. 

These cover a host of potential health and social issues, including:

• Establishing the patient’s risk factors, including family health history
• Reviewing age-appropriate preventive screenings
• Taking height, weight, blood pressure and other routine measurements
• Reviewing current medications, including opioid prescriptions
• Screening for potential mental health and cognitive function issues

What is not covered in a Medicare Annual Wellness Visit?

Because the Medicare Annual Wellness Visits (AWV) focuses on preventive care and health maintenance, CMS does not reimburse for diagnosing or treating current or new medical conditions or symptoms. 

The following are not covered under CPT codes for the AWV:

• Detailed physical examinations
• Diagnosis or discussion of current or new medical symptoms, illnesses or conditions 
• Treatment for new or existing chronic or acute illnesses
• Adjustments or changes to medication prescriptions
• Administering vaccinations
• Diagnostics like bloodwork, lab tests or x-rays