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The Complete Guide to the Annual Wellness Visit

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The Complete Guide to the Annual Wellness Visit

This blog features a full breakdown of Medicare’s Annual Wellness Visit. Understand the AWV’s importance, get the necessary billing codes, and walk through the visit itself, step by step. 

Annual Wellness Visit Table of Contents

Quick, What is the Annual Wellness Visit (AWV)?

It’s a visit to develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA). 

As a health care provider, you may recommend patients get services more often than Medicare covers, including the AWV, or you may
recommend services Medicare doesn’t cover. If this happens, please ensure patients understand they may pay some or all the cost. Communication is key to making sure patients understand why you’re recommending certain services, and whether Medicare pays for them.

What’s Covered?

  • The AWA is covered once every 12 months
  • The patient will pay nothing, as long as the provider accepts the assignment

Why the Annual Wellness Visit Matters

The Annual Wellness Visit is different than a typical physical exam or other preventative care visits. This visit or exam expands more upon a patient’s emotional and psychological well-being, the physical portion is optional. It is an opportunity to improve the patient’s quality of care, engage the patient, and optimize payment opportunities. After the visit, providers can use the collected information to analyze risk factors, recommend appropriate preventative services, and most importantly create a unique prevention plan.

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Breaking Down the Annual Wellness Visit

First, your primary care doctor will ask you to fill out a questionnaire called a Health Risk Assessment that evaluates your health status, frailty and physical functioning.

It also assesses other aspects of your health, such as:

  • Psychosocial risks (e.g., depression/life satisfaction, stress, anger, loneliness/social isolation, pain, and fatigue)
  • Behavioral risks (e.g.,  tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety and home safety)
  • Activities of daily living (e.g., dressing, feeding, toileting, bathing, grooming, physical ambulation including balance and your risk of falls)

After reviewing this assessment, your primary care doctor will likely provide a variety of other services and talk to you about preventable health diseases.

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The AWV and the HRA

The AWV includes an HRA. See the summary below of the minimum elements in the HRA. Get more information in the CDC’s
booklet, including:

  • A Framework for Patient-Centered Health Risk Assessments 
  • Evidence suggests HRA use and follow-up interventions can positively influence health behaviors
  • Definition of the HRA framework and rationale for its use
  • Guidance on HRA use, reduction of health disparities, and improving health outcomes through identifying modifiable health
    risks and providing behavior change interventions
  • Sample HRA

What is the HRA?

The Health Risk Assessment is another screening tool that helps patients and doctors identify patient health risks and monitors their health status over time. Similar to the IPPE and AWV, it seeks to prevent future health risks and complications. 

Preparing Eligible Medicare Patients for the AWV

Providers can help eligible Medicare patients prepare for their AWV by encouraging them to bring the following information:

  • Medical records, including immunization records
  • A detailed family health history
  • A full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
  • A full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals) and behavioral health specialists

13 Initial AWV Components:

This applies to the first time a patient gets an AWV

  1. Perform Health Risk Assessment (HRA)
    1. Get patient self-reported information
      • You or the patient complete the HRA before or during the AWV; it shouldn’t take more than 20 minutes
      • Consider the best way to communicate with underserved populations, people with limited English proficiency, health literacy needs, and persons with disabilities.
          • At a minimum, collect information about:
              • Demographic data
              • Health status self-assessment
              • Psychosocial risks include, but are not limited to depression/life satisfaction, stress, anger, loneliness/social isolation, pain, and fatigue
              • Behavioral risks include, but are not limited to tobacco use, physical activity, nutrition, and oral health, alcohol consumption, sexual health, motor vehicle (for example, seat belt use), and home safety
              • Activities of Daily Living (ADLs) including dressing, feeding, toileting, grooming, physical ambulation including balance/risk of falls and bathing; and Instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, mode of transportation, shopping, managing medications, and handling finances
  2. Establish patient’s medical and family history
      1. At a minimum, document:
          • Medical events of the patient’s parents, siblings, and children including hereditary conditions that place them at increased risk
          • Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments
          • Use of, or exposure to, medications and supplements, including calcium and vitamins
  3. Establish a list of current providers and suppliers
      1. Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.
  4. Measure:
      1. Height
      2. Weight
      3. Body Mass Index (BMI) (or waist circumference, if appropriate)
      4. Blood pressure
      5. Other routine measurements deemed appropriate based on medical and family history
  5. Detect any cognitive impairment patients may have
      1. Assess cognitive function by direct observation, considering information from the patient, family, friends, caregivers, and others.
      2. Consider using a brief cognitive test, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk.
      3. Find more information on the National Institute on Aging’s Website.
  6. Review patient’s potential depression risk factors, including current or past experiences with depression or other mood disorders
      1. Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. Find more information on depression screening on the Depression Assessments Instruments Website. 
  7. Review patient’s functional ability and level of safety
      1. Use direct patient observation, or appropriate screening questions or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, these areas:
          • Ability to perform Activities of Daily Living (ADLs)
          • Fall risk
          • Hearing impairment
          • Home safety
  8. Establish an appropriate written screening schedule for patients, such as a checklist for the next 5–10 years
      1. Base written screening schedule on the:
  9. Establish a list of patient risk factors and conditions where primary, secondary, or tertiary interventions are recommended or underway
      1. Mental health conditions including depression, and cognitive impairment substance use disorder(s) (https://www.samhsa.gov/find-help/disorders)
      2. IPPE risk factors or conditions identified
      3. Treatment options and associated risks and benefits
  10. Provide patient’s personalized health advice and appropriate referrals to health education or preventive counseling services or programs
      1. Include referrals to educational and counseling services or programs aimed at:
          • Community-based lifestyle interventions to reduce health risks and promote self management and wellness including:
              • Fall prevention
              • Nutrition
              • Physical activity
              • Tobacco-use cessation
              • Weight loss
              • Cognition
  11. Provide Advance Care Planning (ACP) services at the patient’s discretion
      1. ACP is a discussion between you and the patient about:
          • Their preparation of an advance directive in case an injury or illness prevents them from making health care decisions
          • Future care decisions they might need to make
          • How they can let others know about care preferences
          • Caregiver identification
          • Explanation of advance directives, which may involve
            completing standard forms
      2. Note: “Advance directive” is a general term referring to various documents such as a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent and/or records a person’s wishes about their medical treatment used at a future time when the individual is unable to speak for themselves.
  12. Review current opioid prescriptions
      1. For a patient with a current opioid prescription:
          • Review their potential Opioid Use Disorder (OUD) risk factors
          • Evaluate their pain severity and current treatment plan
          • Provide information on non-opioid treatment options
          • Refer to a specialist, as appropriate
          • Get more information on pain management in this report.
  13. Screen for potential Substance Use Disorders (SUDs)
      1. Review the patient’s potential risk factors for SUDs and, as appropriate, refer them for treatment. A screening tool isn’t required but you may use one.
      2. Find more information in this screening chart

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12 Components to the Subsequent Annual Wellness Visit

  1. Perform Health Risk Assessment (HRA)
      1. Get patient self-reported information
          • You or the patient can update the HRA before or during the AWV; it shouldn’t take more than 20 minutes
      2. At a minimum, collect information about:
          • Demographic data
          • Health status self-assessment
          • Psychosocial risks including but not limited to depression/life satisfaction, stress, anger, loneliness/social isolation, pain, and fatigue
          • Behavioral risks including but not limited to tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle (for example, seat belt use), and home safety
          • Activities of Daily Living (ADLs) including dressing, feeding, toileting, grooming, physical ambulation including balance/risk of falls and bathing; and Instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, mode of transportation, shopping, managing medications, and handling finances
    2. Update patient’s medical and family history
        1. At a minimum, update and document:
          • Medical events of the patient’s parents, siblings, and children including hereditary conditions that place them at increased risk
          • Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments
          • Use of, or exposure to, medications and supplements, including calcium and vitamins
    3. Include current patient providers and suppliers that regularly provide medical care, including those added because of the first AWV Personalized Prevention Plan Services (PPPS), and any behavioral health providers.
    4. Measure
        1. Measure:
          • Weight (or waist circumference, if appropriate) and blood pressure
          • Other routine measurements deemed appropriate based on medical and family history
    5. Detect any cognitive impairment patients may have
        1. Assess cognitive function by direct observation, considering information from the patient, family, friends, caregivers, and others. Consider using a brief cognitive test, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Find more information on this website.  
    6. Update patient’s written screening schedule
        1. Base written screening schedule on the:
          • Patient’s HRA, health status and screening history, and age-appropriate preventive services Medicare covers
          • The United States Preventative Task Force and Advisory Committee on Immunization Practices
    7. Update patient’s list of risk factors and conditions where primary, secondary, or tertiary interventions are recommended or underway
        1. Include:
          • Mental health conditions including depression, substance abuse, and cognitive impairment
          • Risk factors or conditions identified
          • Treatment options and associated risks and benefits
    8. As necessary, provide and update patient’s PPPS, which includes personalized patient health advice and referral(s) to health education or preventive counseling services or programs when needed
        1. Include referrals to educational and counseling services or programs aimed at:
          • Community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including:
              • Fall prevention
              • Nutrition
              • Physical Activity
              • Tobacco-use cessation
              • Weight loss
              • Cognition
    9. Provide Advance Care Planning (ACP) services at the patient’s discretion
        1. ACP is a discussion between you and the patient about:
          • Their preparation of an advance directive in case an injury or illness prevents them from making health care decisions
          • Future care decisions they might need to make
          • How they can let others know about care preferences
          • Caregiver identification
          • Explanation of advance directives, which may involve completing standard forms
        2. Note:
          • “Advance directive” is a general term referring to various documents such as a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent and/or records a person’s wishes about their medical treatment used at a future time when the individual is unable to speak for themselves. 
    10. Review current opioid prescriptions
        1. For a patient with a current opioid prescription:
          • Review their potential Opioid Use Disorder (OUD) risk factors
          • Evaluate their severity of pain and current treatment plan
          • Provide information on non-opioid treatment options
          • Refer to a specialist, as appropriate
    11. Screen for potential Substance Use Disorders (SUDs)
        1. Review the patient’s potential risk factors for SUDs and, as appropriate, refer them for treatment. A screening tool isn’t required but you may use one.

AWV Coding, Diagnosis, & Billing

Coding

Use these HCPCS codes to file AWV claims:

AWV HCPCS Codes and Descriptors

G0438 – Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

G0439 – Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

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 (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv.

*Get more information on how to bill HCPCS code G0468 in the
Medicare Claims Processing Manual, Chapter 9, Section 60.2 

Diagnosis

Report a diagnosis code when submitting an AWV claim. Since Medicare doesn’t require you to document a AWV
diagnosis code, you may choose any diagnosis code consistent with the patient’s exam.

Billing

Medicare Part B covers an AWV if performed by a:

  • Physician (a Doctor of Medicine or Osteopathy)
  • Qualified Non-Physician Practitioner (NPP) (a Physician Assistant [PA], Nurse Practitioner [NP], or Certified Clinical Nurse Specialist [CCNS])
  • Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of medical professionals directly supervised by a physician

When you provide an AWV and a significant, separately identifiable, medically necessary Evaluation and Management (E/M)service, Medicare may pay the additional service. Report the additional CPT code with modifier –25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury, or to improve the functioning of a malformed body part. You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV and G0439 is for subsequent AWVs.

Remember, you must not bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. Medicare denies these claims with messages of “Benefit maximum for this time period or occurrence has been reached” and “Consult plan benefit documents/guidelines for information about restrictions for this service.” 

Advance Care Planning (ACP) is an Optional Annual Wellness Visit Element

ACP is the face-to-face conversation between a Medicare physician (or other qualified health care professional) and a patient to discuss their health care wishes and medical treatment preferences if they become unable to speak or make decisions about their care. At the patient’s discretion, you can provide the ACP at the time of the AWV.

Coding

Use these CPT codes to file ACP claims as an optional AWV element:

ACP CPT Codes and Descriptors

99497- Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

99498-  Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Diagnosis

You must report a diagnosis code when submitting an ACP claim as an optional AWV element. Since Medicare doesn’t require you to document a specific ACP diagnosis code as an optional AWV element, you may choose any diagnosis code consistent with a patient’s exam.

Billing

Medicare waives both the ACP coinsurance and the Medicare Part B deductible when:

  • Provided on the same day as the covered AWV
  • Provided by the same provider as the covered AWV
  • Billed with modifier –33 (Preventive Service)
  • Billed on the same claim as the AWV

Medicare waives the ACP deductible and coinsurance once per year when billed with the AWV. If the AWV billed with ACP is denied for exceeding the once-per-year limit, Medicare will apply the ACP deductible and coinsurance.

The deductible and coinsurance apply when you deliver the ACP outside of the covered AWV. There are no limits on the number of times you can report ACP for a certain patient in a certain time period. When billing this patient service multiple times, document the change in the patient’s health status and/or wishes regarding their end-of-life care.

Annual Wellness Visit FAQs

What are the other Medicare Part B preventive services?

  • Advance Care Planning (ACP) as an Optional AWV Element
  • Alcohol Misuse Screening & Counseling
    Annual Wellness Visit (AWV)
  • Bone Mass Measurements
  • Cardiovascular Disease Screening Tests
  • Colorectal Cancer Screening
  • Counseling to Prevent Tobacco Use
  • Depression Screening
  • Diabetes Screening
  • Diabetes Self-Management Training (DSMT)
  • Flu, Pneumococcal, & Hepatitis B Shots and their Administration
    Glaucoma Screening
  • Hepatitis B Screening
  • Hepatitis C Screening
  • Human Immunodeficiency Virus (HIV) Screening
  • Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
  • IBT for Obesity
  • Initial Preventive Physical Examination (IPPE)
  • Lung Cancer Screening
  • Medical Nutrition Therapy (MNT)
  • Medicare Diabetes Prevention Program (MDPP)
  • Prolonged Preventive Services
  • Prostate Cancer Screening
  • Screening for Cervical Cancer with
  • Human Papillomavirus (HPV) Tests
  • Screening for Sexually Transmitted Infections (STIs) & High Intensity Behavioral Counseling (HIBC) to Prevent STIs
  • Screening Mammography
  • Screening Pap Tests
  • Screening Pelvic Examination (includes a clinical breast examination)
  • Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)

Are clinical laboratory tests part of the IPPE or AWV?

No. The IPPE and AWV don’t include clinical laboratory tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV

Does the deductible or coinsurance/copayment apply for the AWV?

No. Medicare waives the AWV coinsurance or copayment and the Medicare Part B deductible.

Who is eligible for the AWV?

Medicare covers an AWV for all patients who aren’t within 12 months after the eligibility date for their first Medicare Part B benefit
period and who didn’t have an IPPE or an AWV within the past 12 months. Medicare pays for only 1 IPPE per patient per
lifetime and 1 additional AWV per year thereafter.

Can I bill an electrocardiogram (ECG/EKG) and the AWV on the same date of service?

Generally, you may provide other medically necessary services on the same date as an AWV. The or copayment apply for these other medically necessary and reasonable services deductible and coinsurance 

How do I know if a patient already got their first AWV from another provider and whether to bill for a subsequent AWV even though this is the first AWV I provided to this patient?

You have different options for accessing AWV eligibility information depending on where you practice. You may access the
information through the Health Insurance Portability and Accountability Act Eligibility Transaction System or through the provider call center Interactive Voice Responses (IVRs).  We suggest providers check with their MAC for available options to verify patient eligibility.

Resources for Blog

Medicare Claims Processing Manual (cms.gov)

Medicare Benefit Policy Manual (cms.gov)

Additional Resources

The Complete Guide to the Initial Preventative Physical Exam

Top 10 Benefits to Telepsychiatry

Progessive Therapeutics: Telehealth Security Case Study

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