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Annual Wellness Visit to Provide Personalized Preventive Plan Benefit

Annual Wellness Visit Benefit Overview

What does Medicare pay for AWV services?

The Medicare 2011 payment, independent of an adjustment for geography, for the first annual AWV service, G0438, is $172.18 and the payment for the subsequent annual service, G0439, is $111.35. These payment amounts are based on the 2010 Medicare dollar multiplier for converting relative value units to payment amounts, or conversion factor, which is $36.87. Congress enacted a law that prevents the large, untenable cut generated by the flawed Sustainable Growth Rate formula that was scheduled to take effect January 1, 2011 by replacing it with a continuation of the 2010 payment rates.

CMS determined that the resources that a physician incurs to furnish the first AWV service is equivalent to the resources involved in providing a relatively high level new patient office visit service, CPT 99204. Thus, the agency assigned relative value units to the first AWV that are equal to the relative value units it assigns to 99204. The CMS relative value unit assignment for the Welcome to Medicare visit service is also tied to the values assigned to 99204. CMS views the resources involved in all of these services as equal.

CMS assigned relative value units to the subsequent AWV by setting them as equal to a relatively high level established patient office visit service, CPT 99214.

The expectation is that an AWV service will typically be furnished in the office or outpatient setting. While an AWV service can be provided in the inpatient setting, the payment for an inpatient service is the same as for an AWV service furnished to an outpatient.

A table summarizing the key information related to 2011 payment for AWV services is below. CMS will reassess its AWV relative value unit assignments if the required service elements change, e.g. the addition of the beneficiary health risk assessment element, and/or if the relative value units assigned to comparable services change.

Code Work RVU Total RVU Payment
Amount*
Service Referenced
as Equal
G0438 2.43 4.67 $172.18 99204; G0402
G0439 1.50 3.02 $111.35 99214

*Payment amount determined using a 2011 Medicare conversion factor that is equal to its 2010 level.

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