One of the biggest misconceptions about the Annual Wellness Visit is that it’s an extensive physical exam. Annual physical exams are generally more comprehensive and often include blood work with a broad list of physical exams. A Medicare Annual Wellness Visit doesn’t typically include physical contact, but the visit is used to understand a patient’s current state of health and create a personalized care plan. The care plan, or Personalized Prevention Plan Services (PPPS) consists of both short and long term preventative health measures. The Centers for Medicare and Medicaid Services (CMS) uses Annual Wellness Visits as a tool for primary care physicians to take a proactive approach in helping their Medicare patients stay healthy and ultimately reduce per-capita health care costs. 

Types of Medicare Wellness Visits and Who’s Eligible

Initial Preventive Physical Exam (IPPE)

New Medicare patients are eligible for the “Welcome to Medicare” preventative visit called the Initial Preventative Physical Exam (IPPE). Medicare covers the cost of one IPPE per lifetime as long as it’s provided within the first 12 months of the patient’s Medicare Part B enrollment. The HCPCS billing code for the IPPE is G0402. 

Initial Annual Wellness Visit

12 months after their IPPE visit, Medicare patients are eligible for a free Initial Annual Wellness Visit. If a patient skipped their IPPE in the first 12 months, they are eligible for this visit 12 months after they enrolled in Medicare Part B. This visit is also covered once in a lifetime and is more comprehensive than Subsequent Annual Wellness Visits with the goal of setting a baseline for a patient's health history. The HCPCS billing code for initial AWVs is G0438. 

Subsequent Annual Wellness Visit

Subsequent AWVs are available annually, 12 months after the initial AWV. One thing to note is that AWVs don’t need to be scheduled 365+ days after the previous AWV. They can be scheduled within the same calendar month in the next year. For example, a patient could complete an AWV on February 28th, 2024 and schedule their next AWV as soon as February 1st, 2025. The HCPCS billing code for subsequent AWVs is G0439. 

What is evaluated during a Medicare Annual Wellness Visit? 

Before or during an Annual Wellness Visit, patients must complete a Health Risk Assessment (HRA) form. The HRA is used to capture and document health information that will be used to create a Personalized Prevention Plan Services (PPPS). Below is a list of information collected on the HRA form and included in the PPPS:

• Patient demographics
• Self-assessment of current health state
• Psychosocial risks
• Behavioral risks
• Activities of daily living
• Patient’s past medical history and family medical history
• Current health care providers and suppliers (outside of the primary care provider)
• Patient’s vitals including height, weight, BMI, and blood pressure
• Cognitive assessment
• Depression risk factors assessment
• Functional ability and safety assessment (fall risk, hearing, driving, etc)
• Establish a preventative screening schedule
• Establish a list of risk factors and conditions
• Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs
• Provide advance care planning services at the patient’s discretion
• Review and update current prescriptions
• Screen for substance use disorders 
• Social Determinants of Health (SDOH) Risk Assessment (optional)

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Snap eHealth has created a best-in-class Health Risk Assessment form and Personalized Prevention Plan Services to meet the compliance requirements for CMS. If your practice is interested in learning more about our solutions, please contact us here. 

For more information on what should be reviewed and documented during an Annual Wellness Visit, please reference CMS’s Medicare Learning Network page about Medicare Wellness Visits.

The video below was produced by the Centers for Medicare & Medicaid Services and is a great resource for understanding how Medicare Annual Wellness Visits are different from routine physical exams.