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Medicare Replacements and the New Annual Wellness Visits

Nancy Posted Tue 15th of February, 2011 16:13:44 PM

Does any one know if Medicare Replacement policies are recognizing the New Annual Wellness Visit? And, also how is everyone doing with the Annual Wellness Visits? Thanks

SuperCoder Answered Tue 15th of February, 2011 19:15:25 PM

The visit that Medicare covers is not a physical exam or preventive medicine service that you are accustomed to providing, as defined by CPT codes 99381-99397. Those services remain non-covered, and payment will be denied by Medicare. If you provide the services described by CPT 99381 to 99397 to Medicare beneficiaries, you must get an Advanced Beneficiary Notice signed by the patient, since they will be responsible for payment. The keys phrase about the new covered Medicare visits is “to develop or update a preventive plan.” The Annual Wellness Visit was added as a Medicare benefit by the Patient Protection and Affordable Care Act of 2010. It became effective on January 1, 2011.

The Annual Wellness Visit (AWV) is not to be confused with the Welcome to Medicare Visit, also called the Initial Preventive Physical Examination (IPPE), though there are similarities. Only one IPPE may be performed per beneficiary, and an IPPE may be performed only within the first 12-months of the beneficiary’s enrollment in Medicare Part B. No AWV is covered until 12 months after the IPPE, or until 12 months after the date of enrollment, if no IPPE is performed. CMS has indicated that CPT codes 99381 to 99397 should not be billed to the patient during an encounter when an AWV is billed.

There are two types of AWVs - the first annual wellness visit (G0438) and subsequent annual wellness visits (G0439). G0438 may not be billed if the patient received an IPPE.

The initial Annual Wellness Visit (G0438) includes:

·routine measurements such as height, weight, blood pressure, body-mass index (or waist circumference, if appropriate);

·review of medical and family history;

·establishing a list of current providers, suppliers, and medications (including supplements);

·a personal risk assessment (including any mental health conditions);

·a review of functional ability and level of safety;

·detection of any cognitive impairment;

·screening for depression;

·establishing a schedule for Medicare’s screening and preventive services your client qualifies for over the next 5 to 10 years; and,

·any other advice or referral services that may help intervene and treat potential health risks.

The subsequent Annual Wellness Visits (G0439) include:

·measurement of weight, blood pressure, and other measurements deemed appropriate (note: height and body-mass index not necessary, unless your client has had significant weight change);

·an update to medical and family history;

·an update to the list of providers, suppliers, and medications (including supplements);

·a review of the initial personal risk assessment;

·detection of any cognitive impairment;

·an updated screening schedule; and,

·a review and update to list of referral services to help intervene and treat potential health risks.


There are now three types of preventive visits covered by Medicare:
1. Initial Preventative Physical Examination (IPPE) – G0402
This visit may be performed only within the 12-month period immediately following a beneficiary’s enrollment in Medicare Part B. The Initial Preventative Physical Exam may be billed using HCPCS G0402 and has been valued at the same rate as CPT 99204.

2. First Annual Wellness Visit (AWV) – G0438
This may be billed for new or established patients who have not had a previous Medicare preventative exam, when the AWV is at least 12 months after the patient enrolls in Medicare. The first Annual Wellness Visit is billed using HCPCS G0438 and has been valued the same as CPT 99204.

3. Subsequent Annual Wellness Visit (AWV) – G0439
This may be billed for those Medicare Part B beneficiaries who had an IPPE or AWV no less than 12 months prior to the current wellness visit. The subsequent Annual Wellness Visit is billed using HCPCS G0439 and has been valued the same as CPT 99214.

These three services, as well as other specified screenings and vaccinations, are not subject to Medicare Part B deductibles and co-pays. Preventive screening services that are covered by Medicare and that are exempt from deductibles and co-pays include, but are not limited to, screening mammography, screening pap smear, screening pelvic exam, and bone mass measurement. The Medicare Learning Network has additional information about these and other Medicare services at

Nancy Posted Tue 15th of February, 2011 21:00:26 PM

Thank You for all the great information, but what I really needed to know is if the Medicare Replacement policies are following Medicare guidelines. We are getting denials when we bill the Annual Wellness Visits to the replacement policies.

SuperCoder Answered Tue 15th of February, 2011 21:09:22 PM

This is always a regular phenomena, and we need to convince the medicare rep. Let's be careful on the following while talking to Medicare rep for reimbursement of the claim in this regard:
1. We need to jot down the points with exact frame of guidelines that we follow which justify for a reimbursement.

2. The exact framing of words and sentences have to be carefully drafted before speaking to medicare rep with exact data on Date of Service wise, Date of effectiveness of Insurance, and how the service justify for reimbursement.

Shannon Answered Tue 15th of February, 2011 22:25:24 PM

usually if it is covered by Medicare, than replacement policies will cover. This is from my experience

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