- Who can perform the AWV
- Knowing which Medicare wellness visit to bill
- Eligibility requirements for the Welcome to Medicare visit
After I gave a presentation at a family medicine conference a physician said to me, “What you just told me will pay for the entire cost of my coming to this conference.” I don’t always hear that after I give a presentation. Sometimes I hear the opposite.
Who can perform the AWV?
Question:
Can a nurse or health educator or pharmacist perform an Annual Wellness Visit (AWV)?
Answer:
Yes.
An initial or subsequent AWV may be performed by physician, a qualified health care professional (nurse practitioner, physician assistant or clinical nurse specialist) or by “Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of medical professionals who are directly supervised by a physician (doctor of medicine or osteopathy).”[1]
- The above quote was removed from the updated MLN document about wellness visits, but the 2024 Final Rule, quoted below, acknowledges that these services may be performed by someone without E/M in their scope of practice.
- When an AWV is performed by other professionals, such as health educators, registered nurses or pharmacists, the service is furnished under the “direct supervision” of a physician. Direct supervision means the physician is in the suite of offices when the service is being performed. The quote above says, “directly supervised.”
- Nurse practitioners, physician assistants and clinical nurse specialists are all licensed to perform E/M services and may perform the AWV. CMS does not allow those practitioners to be the billing provider when a health educator or nurse or team perform the service.
What about AWV as initiating visits for chronic care management?
In this discussion from the 2024 PFS Final Rule, CMS notes that the AWV can be furnished by professionals who don’t have diagnosis and treatment in their scope of practice. In shorthand, this means professionals who can’t bill an E/M service (office visit, hospital visit). E/M services may only be performed by those who do have diagnosis and treatment in their practice scope. But when the wellness visit is performed by an individual who doesn’t have E/M in their scope of practice, it can’t serve as the initiating visit for care management services.
“Under section 1861(hhh)(3)(C) of the Act, the AWV can be furnished by a physician or practitioner or by other types of health professionals whose scope of practice does not include the diagnosis and treatment involved in E/M services, for example, a health educator.”[2]
“Our final policy requires the individual billing for the initiating visit to be the same as the practitioner billing for CHI. In order to bill for these services, practitioners must have a statutory benefit and be able to enroll and bill Medicare as they would for other services on the fee schedule and specifically be able to bill an E/M service that would serve as the initiating visit.” [3]
• If an AWV is done by professionals other than a physician, nurse practitioner, physician assistant or clinical nurse specialist,[4] it cannot serve as an initiating visit for any incident to service, such as care management services or Community Health Integration (CHI). That is, if a health educator does an AWV and the patient needs chronic care management, the AWV cannot serve as an initiating visit. The patient would need to see a physician or NPP for a visit that would serve as an initiating visit.
[1] The ABC’s of the Annual Wellness Visit, (AWV) CMS MLN Matters, ICN 905706 April 2017 p. 10
[2] CMS’s 2024 Physician Fee Schedule Final Rule, display copy, p. 309
[3] CMS’s 2024 Physician Fee Schedule Final Rule, display copy, p. 311
[4] Note: these are all practitioner who can enroll in Medicare and have E/M in their scope of practice
Incorrect coding equals lost revenue
The mistake he was making that was costing him money is the same mistake I saw recently in a large primary care group. It was billing a subsequent annual wellness visit when the patient was eligible for an initial annual wellness visit.
The physician, like the group I visited recently, billed the Welcome to Medicare visit in the first year the patient was enrolled in Medicare and then billed a subsequent wellness visit the next year. They missed the initial annual wellness visit.
The correct sequence is:
- First, bill the Welcome to Medicare visit. The patient is eligible for this service within the first year of enrollment with Medicare.
- Second, bill the initial annual wellness visit. The patient is eligible for this after 11 full months have passed since the Welcome to Medicare visit, or if they didn’t have the Welcome to Medicare visit in the first full year of enrollment.
- Third, bill the subsequent annual wellness visit (after 11 four months have past and every year thereafter).
Why does it make such a big difference?
The payment for the initial annual wellness visit is much higher than the payment for the subsequent wellness visit.
Run a CPT® frequency report
My first suspicion that the group was billing these incorrectly was when I looked at the volume for these three visits. There weren’t many initial annual wellness visits.
If you are wondering if the primary care clinicians in your group and the coders understand this, run a frequency report that shows the number of times these three codes were billed. (G0402, G0438 and G0439)
If G0438 is billed less frequently than G0402, be suspicious.
How can a clinician know which visit to bill?
They can’t, without staff help. Staff can look this up, however.
https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp
I suggest using the same template for all three visits.
There are slight variations in the requirements, so develop a template that meets the requirements of both the Welcome to Medicare visit and the wellness visits.
- G0402 requires the testing of visual acuity, and with patient permission, end-of-life planning
- G0438 and G0439 require a list of current medical providers, a health risk assessment, and an assessment of cognitive function. The content of the health risk assessment is usually in the screening for the Welcome to Medicare visit.
This allows you to bill any one of the three visits based on the documentation.
Check your MACs website
Office staff can check their Medicare Administrative Contractor’s (MAC) website to determine which visit the patient is eligible for. Or, the CMS site above.
While it is true that this takes time to do and can be difficult in a busy practice, it saves the time of resubmitting claims that were denied.
Don’t miss billing the Initial Annual Wellness Visit!
CMS updated the MLN Matters article in October of 2020. You can find it https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html.
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
Additional resources:
- Preventive Medicine Services – Medicare
- Preventive medicine and Medicare wellness with E/M | Webinar
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