Focus on Health System Reform: Annual Wellness Visit

Since 2005 Medicare patients have been eligible to receive an Initial Preventive Physical Exam, also known as the Welcome to Medicare Exam, within the first 12 months of enrollment.  In Section 4103 of the Patient Protection and Affordable Care Act, Congress again expanded Part B Medicare coverage to include an annual wellness visit at no out-of-pocket cost to the patient.  This benefit is available beginning January 1, 2011. 

CMS and local administrative carriers have been heavily promoting this new benefit and urging Part B patients to use it since the PPACA was enacted earlier this year.  The result has been a flood of calls from eligible beneficiaries to doctors offices looking to schedule their “free physical.”  But until this week very little useful information was available to medical practices on how to provide the service, when to provide the service, or how to bill the service.

The annual wellness visit includes a health risk assessment and the creation or review of a personalized prevention plan.  The prevention plan must include certain elements, such as patient medical history, family history, current providers and medications, a listing of risk factors, and more.  As for which patients are eligible, Medicare will make payment for an annual wellness visit if provided on or after January 1, 2011, for an individual who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and has not received either an initial preventive physical or an annual wellness visit in the last 12 months. 

Just yesterday CMS released a Medicare Learning Network Bulletin containing additional information to physician practices about how to administer and bill for the annual wellness visit.  It is important for you and your practice staff to review this document if you will be providing this service.  

Some other details that NCMS has learned:

  • CMS is creating 2 new HCPCS codes for billing these procedures – G0438 (first annual wellness visit with prevention plan) and G0439 (subsequent annual wellness visit with prevention plan).
  •  These codes are valued for payment under the Medicare Physician Fee Schedule using a crosswalk methodology from the Level 4 new and established patient office or other outpatient visit CPT codes.
  • The CPT code for a medically necessary E/M visit may be reported and amended with CPT modifier -25 to designate the E/M visit as a separately identifiable service from the annual wellness visit when both are provided in the same encounter.

Affected physician offices should also watch for additional details from CIGNA Government Services on this item or contact NCMS if any problems arise when administering or billing for the annual wellness visit.


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1 Comment

  • CMS stated in the final regulations that they believe if a patient’s medical problems are not stable, it is not the appropriate time to perform the Annual Wellness Visit. CMS stated “we believe this scenario to be uncommon and we expect that no components of an encounter attributable to the annual wellness visit would be used in determining the level of a separate E/M visit that would also be reported.
    Use modifier -25 with caution.