Preventive Services

Preventive Services Guide

Annual Wellness Visit Screening

Table of Contents

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Annual Wellness Visit Screening

The AWV screening is part of the Patient Protection and Affordable Care Act of 2010. The AWV is a preventive wellness visit, not a routine physical checkup.

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Coverage Criteria

  • Annual benefit for all Medicare Part B patients
    • Eleven full calendar months must pass after the month in which a beneficiary had received an AWV
  • Beneficiaries who are no longer within 12 months of the effective date of their Part B coverage period and have not received either an IPPE or AWV within past 12 months

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Two Types of AWV

  • Initial
    • Only one covered per lifetime
      • G0438: Annual wellness visit, includes PPPS, first visit
  • Subsequent
    • Covered annually
      • G0439: Annual wellness visit, includes PPPS, subsequent visit
  • No specific ICD-10 code required for AWV, report the appropriate diagnosis code

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Elements

Health risk assessment – an evaluation tool that meets the following criteria:

  • Collects self-reported information about the beneficiary
  • Can be administered independently by beneficiary or administered by a health professional prior to, or as part of, the AWV encounter
  • Is appropriately tailored to and takes into account the communication needs of underserved
  • Takes no more than 20 minutes to complete

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Elements of Initial AWV

HRA at a minimum, address the following topics:

  • Demographic data
  • Self-assessment of health status
  • Psychosocial risks
  • Behavioral risks
  • ADL and instrumental ADL

Establishment of medical/family history, must include:

  • Past medical/surgical history
  • Use of, or exposure to medications and supplements
  • Medical events – parents, siblings, children

Establish of list of current providers and suppliers regularly involved in providing medical care to patient.

Measurement of:

  • Height
  • Weight
  • BMI or waist circumference, if appropriate
  • Blood pressure
  • Other routine measurements as appropriate

Detection of cognitive impairment

  • Includes assessment of cognitive function by direct observation

Review of risk factors for depression

  • Includes current or past experiences with depression or other mood disorders
  • Use nationally-recognized screening instrument for persons without current depression diagnosis

Review functional ability and level of safety

  • Based on direct observation or use of screening questions, or nationally recognized screening questionnaire
  • Must include an assessment of:
    • Hearing impairment
    • Ability to successfully perform ADLs
    • Fall risk
    • Home safety

Establish a written screening schedule based on:

  • Health status
  • Screening history
  • Age appropriate Medicare preventive services

Establish a list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or underway.

  • Include mental health conditions and risk factors or conditions identified through IPPE and a list of treatment options with associated risks and benefits

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Personalized Prevention Plan Services – Health Advice and Referrals

  • Health education or preventive counseling services and programs
  • Community based lifestyle interventions including:
    • Weight loss
    • Physical activity
    • Smoking cessation
    • Fall prevention
    • Nutrition

For a patient with a current opioid prescription:

  • Review their potential OUD risk factors
  • Evaluate their pain severity and current treatment plan
  • Provide information on nonopioid treatment options
  • Refer to a specialist, as appropriate

More information on pain management can be found in the HHS Pain Management Best Practices Inter-agency Task Force Report.

Screen for potential SUDs:

Provide ACP services at patient’s discretion. ACP is a discussion between you and the patient about:

  • Their advance directive preparation in case an injury or illness prevents them from making health care decisions.
  • Future care decisions they may need to make.
  • How they can let others know about care preferences.
  • Caregiver identification.
  • Advance directives explanation, which may involve completing standard forms.

Advance directive is a general term referring to various documents such as a living will, instruction directives, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual cannot communicate for themselves. View MLN® Fact Sheet: Advance Care Planning for more information.

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Subsequent AWV Elements

  • Includes:
    • Review of an HRA
    • Update of medial family history (As mentioned above, Medicare would like to include opioid use in the ‘Review of Medical and Family History’ element of the AWV. Providers are encouraged to pay close attention to opioid use during this element of the AWV. If a patient is using opioids, assess the benefit from other, nonopioid pain therapies instead, even if the patient does not have OUD but is possibly at risk.)
    • Update list of current providers regularly involved in providing medical care
    • Measurement of weight or waist circumferences, blood pressure and other routine measurements as appropriate
    • Detection of any cognitive impairment
    • Update to list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or underway
    • Update to written screening schedule developed during first AWV
    • Furnished personalized health advise/referral
      • Health education
      • Preventive counseling services or programs

For a patient with a current opioid prescription:

  • Review their potential OUD risk factors
  • Evaluate their pain severity and current treatment plan
  • Provide information on nonopioid treatment options
  • Refer to a specialist, as appropriate

More information on pain management can be found in the HHS Pain Management Best Practices Inter-agency Task Force Report.

Screen for potential SUDs:

Provide ACP services at patient’s discretion. ACP is a discussion between you and the patient about:

  • Their advance directive preparation in case an injury or illness prevents them from making health care decisions.
  • Future care decisions they may need to make.
  • How they can let others know about care preferences.
  • Caregiver identification.
  • Advance directives explanation, which may involve completing standard forms.

Advance directive is a general term referring to various documents such as a living will, instruction directives, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual cannot communicate for themselves. View MLN® Fact Sheet: Advance Care Planning for more information.

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Advance Care Planning with AWV

Face-to-face optional voluntary service between the physician (or other qualified health care professional) and patient discussing advance directives with or without completing relevant legal forms.

  • 99497: ACP including the explanation and discussion of advance directives such as standard forms 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: Each additional 30 minutes (List separately in addition to code for primary procedure)
    • Use 99498 in conjunction with 99497
  • ACP must be billed with modifier 33
  • When performed on the same day by the same provider, considered preventive service
    • Coinsurance/deductible waived

Social Determinants of Health Risk Assessment

SDOH is important in assessing patient histories; in assessing patient risk; and in guiding medical decision making, prevention, diagnosis, care and treatment. In the CY 2024 Medicare Physician Fee Schedule final rule, we added a new SDOH Risk Assessment as an optional, additional element of the AWV. At both yours and the patient’s discretion, you may conduct the SDOH Risk Assessment during the AWV.

Coding

  • Use this HCPCS code to file SDOH Risk Assessment claims as an optional AWV element:
    • G0136 - Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes
  • Report a diagnosis code when submitting an SDOH Risk Assessment claim as an optional AWV element. We don’t require you to use a specific SDOH Risk Assessment diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

Billing

  • The implementation date for SDOH Risk Assessment claims is 7/1/2024. We waive both the Part B SDOH Risk Assessment coinsurance and deductible when it’s:
    • 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
  • We waive the SDOH Risk Assessment deductible and coinsurance once per year when billed with the AWV.
  • If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when you deliver the SDOH Risk Assessment outside the covered AWV.

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Additional Services

Other preventive services currently paid separately under Medicare Part B screening benefits not included in AWV.

  • Allowed to be performed at same visit
  • Bill and document according to requirements for each preventive service

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Evaluation and Management (CPT Codes 99201–99215)

  • Must be medically necessary and separately identifiable
  • Do not include AWV components when coding E/M
    • Portion of history or physical exam portion
  • Report with modifier 25 when appropriate

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Who Can Perform?

  • Physician (DM or DO)
  • Qualified NPP (CNS, NP, PA)
  • Medical professionals working under direct supervision of physician including; health educator, registered dietician, nutrition professional or other licensed practitioner

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Cost Sharing

  • Copayment/coinsurance waived
  • Deductible waived

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Reimbursement

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Nonparticipating Providers

  • Nonparticipating reduction applies
  • Limiting charge provision applies

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Common Claim Denials

  • Billed for second initial AWV
  • Subsequent AWV was performed less than 12 full months after the previous covered AWV

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Related Content

Revised 4/18/2024