Annual Wellness Visit to Provide Personalized Preventive Plan Benefit
Annual Wellness Visit Benefit Overview
Can a physician bill Medicare for a “medically necessary” service and an AWV service when both are furnished during the same encounter?
Yes. The physician should append the code indicating the medically necessary service, e.g. 99213, with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service), in addition to billing the appropriate AWV service. CMS states that it expects that “no component of an encounter attributable to the AWV would be used in determining the level of separate E/M service that would also be reported.”
CMS originally stated that it believed the billing of a same encounter/same-date medically necessary and AWV service would be “uncommon.” The agency believed that a physician is better able to discuss health promotion, disease prevention, and educational opportunities with beneficiaries when “their health status is stabilized and the beneficiary is physically receptive.” The CMS statement that it encourages physicians “to be thoughtful regarding the best timing of the AWV to maximize its impact on beneficiary health…” indicates that the agency believes it best for a physician to schedule the AWV as a separate service that attempts to avoid addressing an acute or chronic problem.
Recent ACP discussion with CMS officials discovered that the agency has changed its characterization, and now realizes that the scenario will likely occur commonly. ACP appreciates that CMS has indicated a more reasonable expectation of a service combination that reflects actual practice, including conveying that fact that a patient presents with acute or chronic condition to be addressed during an AWV encounter does not inherently make that beneficiary unstable.
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