Medicare Wellness Visits: Reassessing Their Value to Your Patients and Your Practice

Arnold E. Cuenca, DO, Caqsm, FAAFP; Susan Kapsner, CCS

Disclosures

Fam Pract Manag. 2019;26(2):25-30. 

In This Article

How to Code for Medicare Wellness Visits

The type of wellness visit you report depends on when the patient joined Medicare.

The IPPE is a one-time physical exam performed within the first 12 months of a patient's enrollment under Part B Medicare. The initial AWV can be provided 12 months after the patient first enrolled or 12 months after he or she received the IPPE. A subsequent AWV can then be provided annually.

Physicians should bill for preventive services provided in addition to the AWV or IPPE, many of which carry work relative value units (wRVUs) that can affect their productivity scores and revenue. Some of these services are payable by Medicare in addition to the AWV or IPPE and can be performed several times during the year. However, patients and physicians should be aware that a few of these services do have a copay or deductible. (See "Medicare-covered preventive services.")

If you provide advance care planning (ACP), CPT code 99497 or 99498, at the same visit, make sure to append modifier 33, "Preventive service," so that the usual coinsurance and deductible charged for the ACP is waived.[5] You may need to append modifiers to other preventive service codes as well, to avoid bundling. Practices should check with their Medicare contractor for guidance.

To find out how many wRVUs a particular service is worth, see the 2019 Medicare Physician Fee Schedule) or the wRVU calculator provided by the American Academy of Professional Coders.

Below are some examples of wellness visits and the wRVUs resulting from each one.

Patient 1: A 65-year-old male, who is an established patient of your practice, is seeing you for an initial AWV. His chronic problems include hypertension and dyslipidemia. He is taking hydrochlorothiazide 25 mg per day and atorvastatin 20 mg at bedtime. His history and the health risk assessment he completed confirm he has smoked one pack of cigarettes per day for 34 years. He does not have an advance directive. He rarely drinks alcohol, and his PHQ-2 depression screening score is zero. His vital signs are stable with good blood pressure control. His BMI is 33.7. He requests a digital rectal exam (DRE) because his father had prostate cancer. You create the patient's personalized prevention plan and discuss your clinical recommendations with the patient, who agrees to receive several preventive services, including a lipid panel, diabetes screening, hepatitis C screening, lung cancer screening with a low-dose CT scan, a pneumococcal vaccination, a DRE, and AAA screening with ultrasound. You order the labs and imaging, provide counseling focused on several of the patient's health risk behaviors, and recommend a follow-up visit in six months or sooner if needed to address test results.

Code Description wRVUs
G0438 Initial annual wellness visit 2.43
G0442 Alcohol misuse screening .18
99497–33 Advance care planning 1.50
G0446 Intensive behavioral counseling for cardiovascular disease (CVD) .45
G0447 Face-to-face behavioral counseling for obesity .45
G0102 DRE for prostate cancer screening .17
Totals 5.18

Patient 2: A 77-year-old female, who is an established patient of your practice, is seeing you for her first AWV. She has a Medicare Advantage insurance plan. Her previous office visit was about nine months ago. She has diabetes, hypertension, peripheral neuropathy, glaucoma, mild major depression, anxiety, and COPD. She is due for her routine lab work and is requesting refills of all her medications. She would like a flu shot, but the rest of her immunizations are current. Her list of medications includes metformin 500 mg twice a day, sitagliptin 50 mg daily, lisinopril 10 mg daily, gabapentin 300 mg three times per day, albuterol as needed, tiotropium daily, alprazolam 0.25 mg daily as needed, sertraline 50 mg daily, and dorzolamide ophthalmic twice a day. She has tried in the past to wean herself off the alprazolam but needs it to control her anxiety; she fills her prescription for 30 pills every three or four months, which you confirm via a controlled substance prescription database. Her history, along with her health risk assessment, shows she drinks up to three glasses of wine per day. She does not have an advance directive. Her vital signs are stable with good blood pressure control, and her BMI is 22.4. You address her concerns and order labs appropriate to her chronic medical conditions, refill her medications, order a flu shot, provide counseling related to her health risk behaviors, and discuss your preventive service recommendations as part of her personalized prevention plan, which includes ordering a DEXA scan.

Given the complexity of her health status, you ask her to schedule a follow-up appointment in one week to go over her lab results. Also, because the patient is a Medicare Advantage beneficiary, you remember to assess and report risk-adjusted diagnoses and HCC codes.

Code Description wRVUs
G0438 Initial annual wellness visit 2.43
G0442 Alcohol misuse screening .18
G0443 Face-to-face behavioral counseling for alcohol misuse .45
99497–33 Advance care planning 1.50
G0446 Intensive behavioral counseling for CVD .45
99214–25 Level 4 established patient office visit 1.50
Totals 6.51

Patient 3: A 57-year-old female, who is an established patient of your practice, recently became disabled. She now has dual insurance coverage with Medicare and Medicaid. She is scheduled for her "Welcome to Medicare" visit. She was seeing a partner of yours who recently retired, and she has transferred to you for care. Her last visit was four weeks ago, and her diabetes lab work at that time showed that her A1C was 6.7 and her LDL was 94. She had her annual eye exam two months ago. She has diabetes, hypertension, and end-stage renal disease (ESRD). Her list of medications includes insulin glargine 10 units at bedtime, insulin aspart on a sliding scale, amlodipine 5 mg daily, and pravastatin 10 mg at bedtime. Her history, along with her health risk assessment, shows that she has multiple sex partners. She does not drink alcohol and does not smoke. Her PHQ-2 depression screening is 0. Her last mammogram was three years ago, and her last Pap smear was six years ago. She has not received her pneumococcal vaccine. She has never had a colonos-copy or fecal occult blood testing. She does not have an advance directive. Her vital signs are stable with good blood pressure control and a BMI of 27.1. She has been feeling sick for the last two weeks with sinus infection symptoms. You treat her for a sinus infection, perform a gynecologic exam, and update her pneumococcal vaccination. You discuss and then order screens for hepatitis B, hepatitis C, HIV, and sexually transmitted infections (STIs), in addition to a mammogram. You also agree to make referrals for a colonoscopy and medical nutrition therapy for ESRD. Finally, you ask her to follow up in four to six months or as needed.

Code Description wRVUs
G0402 "Welcome to Medicare" visit/IPPE 2.43
G0442 Alcohol misuse screening .18
99497–33 Advance care planning 1.50
G0445 High-intensity behavioral counseling to prevent STIs .45
G0446 Intensive behavioral counseling for CVD .45
G0101 Pelvic and breast exam .45
99213–25 Level 3 established patient office visit .97
Totals 6.43

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