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Age and wellness visits | Eligibility for Welcome to Medicare

Question:

Does the patient need to be 65 years old in order to bill the Welcome to Medicare Visit?

Answer:

This is almost a trick question. There is no age restriction for billing Medicare for the Welcome to Medicare visit, the initial annual wellness visit or the subsequent annual wellness visit. The patient is eligible for the Welcome to Medicare visit during the first year after enrolling in Medicare. Since most patients enroll at age 65, those patients are indeed eligible from age 65 to 66.

But, although we think of people being eligible for Medicare at age 65, there are many individuals who are eligible for Medicare at a younger age, because they have qualified for Social Security Disability Insurance (SSDI). A patient is eligible for Medicare after 24 months on SSDI. And, other patients for whom Medicare is a Secondary Payer, because they continue to work.

Medicare’s “Medicare Wellness Visits” resource says this about the IPPE, or “Welcome to Medicare” visit,

  • Medicare pays for one patient IPPE per lifetime not later than the first 12 months after the patient’s Medicare Part B benefits eligibility date.
  • Medicare pays the IPPE costs if the provider accepts assignment.
  • The eligibility for the service is based on the patient’s enrollment in Medicare, not age.

This is what is says about eligibility for Annual Wellness Visit services: “Medicare covers an AWV that delivers Personalized Prevention Plan Services (PPPS) for patients who:

  • Are no longer within 12 months after the patient’s Medicare Part B benefits eligibility date
  • Did not get an IPPE or AWV within the past 12 months”

Citations:

Medicare Wellness Visits MLN resource

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html

Additional resources:

  • Wellness visits
  • Medicare Rules

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Relevant Search Terms: IPPE, AWV, annual wellness visits, age limits for wellness visits, Medicare wellness, G0402, G0438, G0439

Last revised December 28, 2020 - Betsy Nicoletti
Tags: Medicare rules, preventive medicine services, primary care, Wellness Visits

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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