Medicare’s Annual Wellness Visit in Wisconsin: Understanding the Benefit and Preventing Denials

National Government Services Jurisdiction 6 MAC by Michael J. Dorris; Carolyn S. Henson, CPC , CAC, CACO, CPC-I, AAPC I-10 Instructor; and Nathan L. Kennedy, Jr., CPC, CHC, CPPM, CPC-I, CPB, CPMA

“Honey, does Medicare pay for an annual physical?” asked one Wisconsin patient. “I don’t know,” his spouse replies. “Call the doctor’s office.” “Hello, I need to schedule an annual physical and I am on Medicare.” “Next Tuesday at 9:00 a.m.? Great, see you then!”

What’s wrong with this scenario? Medicare does not cover an annual physical exam. Since the rollout of the new preventive service called the AWV in 2011, the terminology of “yearly physical” and “Annual Wellness Visit” are being used interchangeably by providers, beneficiaries, and medical professionals alike—but they shouldn’t be. These services may be similar, but are altogether different resulting in unnecessary cost to you and the Medicare beneficiary on original Medicare FFS. AWV can help our seniors stay healthy.

How the AWV Works

After your Medicare patients on original Medicare FFS have been on Medicare Part B for longer than 12 months, they can get an AWV (G0438) to develop or create a prevention plan. Medicare covers one yearly AWV visit every 12 months. There’s no need for the Medicare patient to get the “Welcome to Medicare” preventive visit (G0402) before getting a yearly AWV. If your Medicare patients received the “Welcome to Medicare” preventive visit, they’ll have to wait 12 months before they can get the first yearly AWV.

Year One: First 12 months

Welcome to Medicare IPPE
Billing Code: G0402

Year Two: Second 12 months

Initial AWV
Billing Code: G0438

Year Three and After: Third 12 months and each 12 month period following AWV

Subsequent AWV
Billing Code: G0439

Medicare covers the AWV at no cost to your Medicare patients, if the Medicare physician accepts the assignment. The AWV is not a routine physical check-up. The initial AWV includes the following for patients:

Personalized prevention plan
Health risk assessment
Blood pressure, height, and weight measurements
Review of potential risk factors for depression
Detection of cognitive impairments
Review of functional ability and level of safety
- Hearing
- Ability to successfully perform activities of daily living (walking, eating, etc.)
- Fall risk
- Home safety

Once these services are completed, the Medicare patient will also get a brief written plan, similar to a checklist, letting them know which screenings and other preventive services they’ll need over the next five to 10 years based on 1) personalized health advice; 2) referrals for health education and preventive counseling to help them stay well; and 3) a written screening schedule.

Subsequent yearly AWVs providing PPPS include:

Updates to the patient’s medical/family history.
Measurements of weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on medical and family history.
Updates to the list of current medical providers and suppliers that are regularly involved in the patient’s medical care, as developed at the first yearly AWV.
Detection of any cognitive impairment updates to the patient’s written screening schedule as developed at the first yearly AWV.
Updates to your list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway, as was developed at the patient’s first yearly AWV.
Discussion of personalized health advice and a referral, as appropriate, to health education or preventive counseling services or programs.
An updated health risk assessment.

It’s important to note Medicare pays for only the first AWV per beneficiary per lifetime and pays for one subsequent AWV per year thereafter. There is no Part B deductible or coinsurance.

If a patient needs more than AWV coverage:

Other Medicare services can be added during these AWV visits.
Separate evaluation and management services can be provided and billed at the same visit as the Welcome to Medicare or AWV, provided the services are significant, separately identifiable, and medically necessary to treat the beneficiary’s illness or injury.
The Welcome to Medicare and AWV are free; other services that Medicare pays for may be subject to deductible and copay/coinsurance requirements.

Preventing Denials

Now that you understand the AWV benefits, let’s explore what Wisconsin physicians can do to prevent AWV denials. NGS reviewed claims data from the last several years from Wisconsin original Medicare FFS providers. Wisconsin has over 1 million people on Medicare with over 60% that population enrolled in original Medicare FFS. It was found that 455,407 AWV claims were paid over a three-year period with 42,151 denied as billing errors.

One way to decrease denials is to avoid common AWV billing errors that Wisconsin physicians can easily correct with further education through:

Submitting an AWV before the patient is allowed their next annual visit (frequency).
Submitting an AWV when the patient has not been eligible for Medicare for one year (should bill Welcome to Medicare).
Billing an initial AWV more than once (second and subsequent should be billed as subsequent AWV).
Avoid duplicate submission of the AWV on one date of service.
Submitting of a modifier with the AWV code (typically modifier 25, not valid).
Submitting AWV to original Medicare when the patient is covered by a Medicare Advantage Plan (submission to wrong contractor).

Who Can Perform an AWV?

Additionally, NGS has received many questions on who can perform these visits and where an AWV can be performed. The following health professionals can perform the AWV:

A physician who is a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Social Security Act [the Act]); or,
A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act); or,
A medical professional (including a health educator, registered dietitian, or nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision (as defined in CFR 410.32(b)(3)(ii)) of a physician as defined in this section.

An AWV can be conducted in the following places of service:

04: Homeless shelter
11: Office
12: Home
13: Assisted living facility
14: Group home
15: Mobile unit
16: Temporary lodging
20: Urgent care
22: Outpatient hospital
32: Nursing facility
33: Custodial care
49: Independent care clinic
54: Intermediate care facility
62: Comprehensive outpatient rehab
71: State or local public clinic

AWV Awareness

AWV utilization can be challenging to understand, not only in Wisconsin but across the country. Out of the 455,407 AWV claims paid, the data suggests that less than 11% of Wisconsin people with Medicare are using the AWV benefit each year. The 11% AVW utilization rate is far less than other Medicare preventive services benefits such as cardio screenings, mammograms, and flu shots which tends to have a 70-90% utilization rate on average.

To increase Medicare AWV utilization over the next five years, take the following actions with Medicare providers and people with original Medicare:

Visit our website for free tools, resources, and webinars to help you and your office staff understand AWV guidelines and what to do if your patient needs additional services during an AWV visit.
Educate Medicare seniors that Medicare AWV is not a yearly physical but a wellness check.
Promote the AWV benefits to your Medicare patients at other patient encounters.

Conclusion

Now that we understand the misconceptions, billing errors and most importantly the benefits of Medicare AVW, the Wisconsin Aging community partners are working together to promote AWV benefits to Medicare seniors and how to avoid AWV billing errors with our physicians. For more information about the AWV, visit Medicare.gov.