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Annual Wellness Visit to Provide Personalized Preventive Plan Benefit

Annual Wellness Visit Benefit Overview

The March 2010 federal health care reform law, the Patient Protection and Affordable Care Act (ACA), establishes a new benefit that begins January 1, 2011 that enables Medicare beneficiaries to receive an annual wellness visit that focuses on establishing and then maintaining a personalized prevention plan. A beneficiary is eligible if he or she: has had Medicare Part B coverage for at least 12 months; and has not received either an Initial Preventive Physical Examination, known as the “Welcome to Medicare” visit, service or an annual wellness visit service within the past 12 months.

The ACA specifies the use of a beneficiary-completed risk assessment to establish a personalized prevention plan as an essential element of an annual wellness visit service. This key element is not required for 2011, however, as the Centers for Medicare and Medicaid Services (CMS) was not yet able to accomplish the specific requirements in the ACA that aim to standardize the risk assessment tool and facilitate its use.

Aside from mandating the use of the risk assessment for which it was not practicable to require for 2011, Congress opted to enumerate annual wellness visit service elements that CMS may require. Considering this guidance from Congress, CMS exercised its discretionary authority and identified elements required for a first annual wellness visit (AWV) service and a subsequent AWV service for 2011 The 2011 first AWV service required elements are: establishment of a beneficiary’s medical and family history; establishment of a list of providers and suppliers involved in the beneficiary’s care; measurement of pertinent vitals; detection of cognitive impairments; review of functional ability and level of safety; establishment of a written screening schedule; documentation of a list of risk factors; and provision of personalized health advice. While a physician will not have the opportunity to furnish a subsequent AWV service in 2011, the requirements provide a sense of what will be mandated in future years.

CMS established a billing code that physicians must use to bill for a first AWV service, G0438, and a subsequent AWV service, G0439. The 2011 Medicare payment—not adjusted for geography—is approximately $172 for G0438 and $111 for G0439. Medicare will pay the full amount, meaning that the beneficiary does not have to pay the typical 20 percent copayment nor toward a yet-to-be reached deductible.

Medicare will pay a physician for an AWV service and a medically necessary service, e.g. a mid-level established office visit, Current Procedural Terminology (CPT) code 99213, furnished during a single beneficiary encounter. CMS initially believed that it would be uncommon for the two services to be provided to the same beneficiary on the same date; however, based on advocacy comments provided by ACP and other medical societies, the agency accepts that it will not be so rare an occurrence. CMS cautions that the elements of the AWV must not be replicated in the medically necessary service. Physicians must append modifier -25 (significant, separately identifiable service) to the medically necessary E/M service, e.g. 99213-25, to be reimbursed for both services.

Physicians can continue to bill a beneficiary for a non covered periodic comprehensive preventive service, signified by CPT 99381-99397, as long as the service does not fit the description of an AWV or the Initial Preventive Physical Examination/Welcome to Medicare visit.

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