Early on detection saves lives. Encourage patients to get their preventive services.
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Updates
Note: We revised this product with the post-obit content updates:
Review of current opioid prescriptions and screening for potential Substance Use Disorders (SUDs) during the Initial Preventive Physical Examination (IPPE) and Almanac Wellness Visit (AWV), and making appropriate referrals for treatment
Medicare telehealth uses HCPCS codes G0438 and G0439
Quick Start Guide
The Annual Health Visits video helps health care professionals empathize each of these exams and their purpose, and the requirements when submitting claims for them.
Medicare Physical Exams Coverage
Initial Preventive Physical Examination (IPPE)
Review of medical and social health history and preventive services education
✔Covered just once within 12 months of offset Part B enrollment
✔ Patient pays aught (if provider accepts assignment)
Annual Wellness Visit (AWV)
Visit to develop or update a Personalized Prevention Programme (PPP) and perform a Health Risk Assessment (HRA)
✔Covered once every 12 months
✔ Patient pays nothing (if provider accepts assignment)
Routine Concrete Exam
Exam performed without relationship to treatment or diagnosis for a specific disease, symptom, complaint, or injury
✘Not covered by Medicare; prohibited by statute, notwithstanding, the IPPE, AWV, or other Medicare benefits comprehend some elements of a routine concrete
✘ Patient pays 100% out-of-pocket
The term "patient" refers to a Medicare beneficiary.
Communication Avoids Defoliation
Equally a health care provider, you may recommend patients get services more often than Medicare covers, including the AWV, or you lot may recommend services Medicare doesn't encompass. If this happens, please ensure patients understand they may pay some or all the toll. Communication is key to making certain patients understand why you're recommending certain services, and whether Medicare pays for them.
Initial Preventive Concrete Examination (IPPE)
The IPPE, known every bit the "Welcome to Medicare" preventive visit, promotes good wellness through affliction prevention and detection. Medicare pays for 1 patient IPPE per lifetime non later than the first 12 months later the patient's Medicare Part B benefits eligibility date.
one. Review the patient'due south medical and social history
At a minimum, collect information about:
Past medical and surgical history (experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments)
Current medications and supplements (including calcium and vitamins)
Family unit history (review of medical events in the patient's family unit, including hereditary weather that place them at increased run a risk)
Diet
Physical activities
History of alcohol, tobacco, and illegal drug apply
Get more information about Medicare Substance Use Disorder (SUD) services coverage in the Screening, Brief Intervention, & Referral to Handling (SBIRT) Services booklet.
2. Review patient'due south potential low chance factors, including electric current or past experiences with depression or other mood disorders
Select from diverse standardized screening tools designed for this purpose and recognized by national professional medical organizations. Notice more data on depression screening on the Depression Assessment Instruments website.
3. Review patient's functional power and prophylactic level
Use straight patient observation, or appropriate screening questions or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, these areas:
Ability to perform Activities of Daily Living (ADLs)
Fall risk
Hearing impairment
Habitation safety
iv. Examination
Measure:
Height, weight, Body Mass Index (BMI) (or waist circumference, if appropriate), and blood pressure
Visual vigil screen
Other factors deemed appropriate based on medical and social history and electric current clinical standards
5. End-of-life planning, on patient agreement
Cease-of-life planning is verbal or written information offered to the patient about:
Their ability to fix an advance directive in case an injury or illness prevents them from making health care decisions
If you hold to follow their wishes expressed in an advance directive
six. Review electric current opioid prescriptions
For a patient with a electric current opioid prescription:
Review their potential Opioid Use Disorder (OUD) chance factors
Evaluate their hurting severity and current treatment plan
Provide data on non-opioid treatment options
Refer to a specialist, every bit appropriate
Become more data on hurting management in the HHS Pain Direction Best Practices Inter-agency Job Force Report.
seven. Screen for potential Substance Use Disorders (SUDs)
8. Educate, counsel, and refer based on previous components
Based on the results of the review and evaluation services in the previous components, requite appropriate education, counseling, and referral.
9. Educate, counsel, and refer for other preventive services
Includes a brief written program, such as a checklist, for the patient to get:
A one time-in-a-lifetime screening electrocardiogram (ECG/EKG), as appropriate
Advisable screenings and other preventive services Medicare covers in the AWV
Use these HCPCS codes to file IPPE and ECG/EKG screening claims:
IPPE HCPCS Codes & Descriptors
G0402
Initial preventive physical test; contiguous visit, services limited to new beneficiary during the first 12 months of medicare enrollment
G0403
Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive concrete examination with interpretation and study
G0404
Electrocardiogram, routine ecg with 12 leads; tracing only, without estimation and report, performed as a screening for the initial preventive concrete exam
G0405
Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination
G0468*
Federally qualified health eye (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical test (ippe) or almanac wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv
* Get more information on how to pecker HCPCS lawmaking G0468 in the Medicare Claims Processing Manual, Affiliate 9, Department sixty.2.
Diagnosis
Yous must report a diagnosis code when submitting an IPPE claim. Medicare doesn't require you to document a specific IPPE diagnosis lawmaking, and so you may choose any diagnosis lawmaking consistent with the patient's exam.
Billing
Medicare Part B covers an IPPE when performed by a:
Physician (a Doc of Medicine or Osteopathy)
Qualified Non-Physician Practitioner (NPP) (a Dr. Assistant [PA], Nurse Practitioner [NP], or Certified Clinical Nurse Specialist [CCNS])
When you provide an IPPE and a pregnant, separately identifiable, medically necessary Evaluation and Management (Eastward/M) service, Medicare may pay the additional service. Written report the boosted CPT code (99201–99215) with modifier –25. That portion of the visit must be medically necessary and reasonable to care for the patient'due south disease or injury, or to meliorate the functioning of a malformed body part.
CPT only copyright 2020 American Medical Clan. All rights reserved.
The AWV includes a HRA. See summary below of the minimum elements in the HRA. Get more information in the CDC's A Framework for Patient-Centered Health Risk Assessments booklet, including:
Bear witness suggests HRA employ and follow-upward interventions can positively influence health behaviors
Definition of the HRA framework and rationale for its apply
Guidance on HRA use, reduction of wellness disparities, and improving health outcomes through identifying modifiable health risks and providing beliefs change interventions
Sample HRA
Perform Health Risk Assessment (HRA)
Get patient self-reported information
You or the patient complete the HRA before or during the AWV; information technology shouldn't take more than 20 minutes
Consider the best style to communicate with underserved populations, people with limited English proficiency, health literacy needs, and persons with disabilities
At a minimum, collect information about:
Demographic data
Health condition self-cess
Psychosocial risks including simply non limited to low/life satisfaction, stress, acrimony, loneliness/social isolation, pain, and fatigue
Behavioral risks including but non limited to tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual wellness, motor vehicle (for instance, seat belt use), and abode safe
Activities of Daily Living (ADLs) including dressing, feeding, toileting, grooming, physical ambulation including rest/risk of falls and bathing; and Instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, style of transportation, shopping, managing medications, and handling finances
1. Establish patient's medical and family history
At a minimum, certificate:
Medical events of the patient's parents, siblings, and children including hereditary weather condition that place them at increased run a risk
Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments
Use of, or exposure to, medications and supplements, including calcium and vitamins
two. Plant list of current providers and suppliers
Include current patient providers and suppliers that regularly provide medical intendance, including behavioral health care.
3. Measure
Measure:
Superlative, weight, Body Mass Alphabetize (BMI) (or waist circumference, if advisable), and blood pressure
Other routine measurements deemed appropriate based on medical and family history
four. Observe any cognitive impairment patients may have
Assess cerebral office past direct observation, considering information from the patient, family, friends, caregivers, and others. Consider using a cursory cognitive exam, health disparities, chronic conditions, and other factors that contribute to increased cerebral impairment risk. Notice more information on the National Found on Crumbling's Alzheimer'south and Dementia Resource for Professionals website.
five. Review patient's potential low chance factors, including current or past experiences with depression or other mood disorders
Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. Detect more than information on depression screening on the Depression Assessment Instruments website.
half-dozen. Review patient'due south functional ability and level of safety
Use straight patient observation, or appropriate screening questions or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, these areas:
Power to perform Activities of Daily Living (ADLs)
Fall risk
Hearing impairment
Home safety
7. Plant an appropriate written screening schedule for patients, such as a checklist for next 5–10 years
eight. Constitute list of patient take chances factors and weather condition where main, secondary, or tertiary interventions are recommended or underway
Include:
Mental wellness conditions including low, substance employ disorder(s), and cognitive impairment
IPPE risk factors or conditions identified
Handling options and associated risks and benefits
9. Provide patient'south personalized health advice and appropriate referrals to health education or preventive counseling services or programs
Include referrals to educational and counseling services or programs aimed at:
Customs-based lifestyle interventions to reduce health risks and promote self-management and wellness, including:
Autumn prevention
Nutrition
Physical activity
Tobacco-use cessation
Weight loss
Knowledge
10. Provide Advance Care Planning (ACP) services at patient'due south discretion
ACP is a discussion betwixt you and the patient most:
Their training of an advance directive in instance an injury or disease prevents them from making wellness care decisions
Future care decisions they might need to make
How they tin allow others know about care preferences
Caregiver identification
Explanation of advance directives, which may involve completing standard forms
"Advance directive" is a general term referring to various documents such as a living will, instruction directive, health care proxy, psychiatric advance directive, or wellness intendance power of attorney. It's a document that appoints an amanuensis and/or records a person'due south wishes virtually their medical treatment used at a future time when the private is unable to speak for themselves. Get more than information in the Advance Care Planning fact canvass.
eleven. Review electric current opioid prescriptions
For a patient with a current opioid prescription:
Review their potential Opioid Utilise Disorder (OUD) take chances factors
Evaluate their hurting severity and current treatment plan
Provide information on not-opioid treatment options
Refer to a specialist, as appropriate
Get more data on pain management in the HHS Hurting Management All-time Practices Inter-agency Task Force Written report.
12. Screen for potential Substance Utilize Disorders (SUDs)
1. Review and update Wellness Adventure Cess (HRA)
Get patient self-reported information
You or the patient can update the HRA before or during the AWV; information technology shouldn't accept more than than 20 minutes
At a minimum, collect information almost:
Demographic data
Wellness status self-cess
Psychosocial risks including just not limited to low/life satisfaction, stress, anger, loneliness/social isolation, pain, and fatigue
Behavioral risks including but not express to tobacco utilize, concrete activity, nutrition and oral wellness, alcohol consumption, sexual health, motor vehicle (for example, seat belt employ), and home rubber
Activities of Daily Living (ADLs) including dressing, feeding, toileting, training, physical ambulation including balance/take chances of falls and bathing; and Instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, mode of transportation, shopping, managing medications, and treatment finances
ii. Update patient's medical and family history
At a minimum, update and document:
Medical events of the patient's parents, siblings, and children including hereditary conditions that place them at increased risk
Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments
Use of, or exposure to, medications and supplements, including calcium and vitamins
3. Update listing of current providers and suppliers
Include current patient providers and suppliers that regularly provide medical care, including those added because of the commencement AWV Personalized Prevention Plan Services (PPPS), and any behavioral health providers.
four. Mensurate
Measure out:
Weight (or waist circumference, if appropriate) and blood pressure level
Other routine measurements deemed advisable based on medical and family history
5. Observe whatever cognitive impairment patients may have
Appraise cognitive office past direct observation, considering information from the patient, family unit, friends, caregivers, and others. Consider using a cursory cerebral examination, wellness disparities, chronic weather, and other factors that contribute to increased cerebral impairment gamble. Detect more information on the National Found on Aging's Alzheimer'southward and Dementia Resources for Professionals website.
6. Update patient's written screening schedule
seven. Update patient's list of risk factors and conditions where chief, secondary, or tertiary interventions are recommended or underway
Include:
Mental health weather condition including depression, substance use disorder(s), and cognitive impairment
Risk factors or conditions identified
Treatment options and associated risks and benefits
8. As necessary, provide and update patient's PPPS, which includes personalized patient health communication and referral(due south) to wellness didactics or preventive counseling services or programs when needed
Include referrals to educational and counseling services or programs aimed at:
Community-based lifestyle interventions to reduce wellness risks and promote self-direction and health, including:
Fall prevention
Nutrition
Physical activity
Tobacco-utilize cessation
Weight loss
Noesis
ix. Provide Advance Care Planning (ACP) services at patient's discretion
ACP is a discussion between you and the patient about:
Their preparation of an accelerate directive in case an injury or disease prevents them from making wellness care decisions
Future intendance decisions they might need to make
How they tin let others know well-nigh intendance preferences
Caregiver identification
Explanation of advance directives, which may involve completing standard forms
"Advance directive" is a general term referring to various documents such as a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It'southward a document that appoints an agent and/or records a person's wishes about their medical treatment used at a future time when the private is unable to speak for themselves. Get more data in the Advance Intendance Planning fact sheet.
10. Review electric current opioid prescriptions
For a patient with a electric current opioid prescription:
Review their potential Opioid Employ Disorder (OUD) risk factors
Evaluate their severity of pain and current handling plan
Provide information on non-opioid treatment options
Refer to a specialist, equally appropriate
Get more than information on pain direction in the HHS Hurting Direction Best Practices Inter-bureau Task Force Report.
xi. Screen for potential Substance Apply Disorders (SUDs)
Coding
Utilise these HCPCS codes to file AWV claims:
AWV HCPCS Codes and Descriptors
G0438
Annual wellness visit; includes a personalized prevention programme of service (pps), initial visit
G0439
Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit
G0468*
Federally qualified wellness center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual health visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv
* Get more information on how to bill HCPCS code G0468 in the Medicare Claims Processing Manual, Chapter ix, Section sixty.two.
Diagnosis
Report a diagnosis lawmaking when submitting an AWV claim. Since Medicare doesn't crave yous to certificate a specific AWV diagnosis code, yous may choose whatsoever diagnosis code consistent with the patient's test.
Billing
Medicare Office B covers an AWV if performed past a:
Doctor (a Physician of Medicine or Osteopathy)
Qualified Non-Physician Practitioner (NPP) (a Physician Assistant [PA], Nurse Practitioner [NP], or Certified Clinical Nurse Specialist [CCNS])
Medical professional (including a health educator, registered dietitian, diet professional, or other licensed practitioner), or a team of medical professionals directly supervised by a physician
When you provide an AWV and a significant, separately identifiable, medically necessary Evaluation and Direction (E/M) service, Medicare may pay the additional service. Report the additional CPT code with modifier –25. That portion of the visit must be medically necessary and reasonable to treat the patient's illness or injury, or to improve the functioning of a malformed body part.
Yous can only bill G0438 or G0439 once in a 12-calendar month period. G0438 is for the showtime AWV and G0439 is for subsequent AWVs. Remember, you must not beak G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. Medicare denies these claims with letters of "Benefit maximum for this time menstruum or occurrence has been reached" and "Consult plan do good documents/guidelines for information well-nigh restrictions for this service."
Medicare telehealth uses HCPCS codes G0438 and G0439. Get more information on the List of Telehealth Services webpage.
CPT only copyright 2020 American Medical Association. All rights reserved.
ACP is the confront-to-face chat between a Medicare medico (or other qualified health care professional person) and a patient to discuss their health intendance wishes and medical handling preferences if they become unable to speak or make decisions about their care. At the patient's discretion, you tin can provide the ACP at the fourth dimension of the AWV.
Coding
Use these CPT codes to file ACP claims as an optional AWV element:
ACP CPT Codes and Descriptors
99497
Accelerate care planning including the explanation and word of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health intendance professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
99498
Advance intendance planning including the explanation and discussion of advance directives such every bit standard forms (with completion of such forms, when performed), by the md or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)
Diagnosis
You lot must report a diagnosis lawmaking when submitting an ACP merits as an optional AWV chemical element. Since Medicare doesn't crave you lot to certificate a specific ACP diagnosis code every bit an optional AWV chemical element, yous may choose any diagnosis code consistent with a patient'south exam.
Billing
Medicare waives both the ACP coinsurance and the Medicare Part B deductible when:
Provided on the same 24-hour interval as the covered AWV
Provided by the aforementioned provider as the covered AWV
Billed with modifier –33 (Preventive Service)
Billed on the same claim equally the AWV
Medicare waives the ACP deductible and coinsurance one time per year when billed with the AWV. If the AWV billed with ACP is denied for exceeding the in one case-per-year limit, Medicare will apply the ACP deductible and coinsurance.
The deductible and coinsurance apply when you lot deliver the ACP outside of the covered AWV. There are no limits on the number of times y'all can report ACP for a sure patient in a sure fourth dimension menstruation. When billing this patient service multiple times, document the alter in the patient's health status and/or wishes regarding their end-of-life care.
Preparing Eligible Medicare Patients for the AWV
Providers tin help eligible Medicare patients prepare for their AWV by encouraging them to bring the following information:
Medical records, including immunization records
A detailed family health history
A total list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
A full list of electric current providers and suppliers involved in their intendance, including community-based providers (for example, personal intendance, adult twenty-four hours care, and dwelling-delivered meals) and behavioral health specialists
CPT only copyright 2020 American Medical Clan. All rights reserved.
IPPE, AWV, & Routine Concrete – Know the Differences
IPPE
The IPPE, known every bit the "Welcome to Medicare" preventive visit, promotes skillful health through disease prevention and detection.
Medicare pays 1 patient IPPE per lifetime not later than the get-go 12 months subsequently the patient's Medicare Part B benefits eligibility date.
Medicare pays the IPPE costs if the provider accepts assignment.
AWV
Medicare covers an AWV that delivers Personalized Prevention Plan Services (PPPS) for patients who:
Aren't within 12 months after the patient's offset Medicare Role B benefits eligibility date
Didn't get an IPPE or AWV within the past 12 months
Medicare pays the AWV costs if the provider accepts assignment and the deductible doesn't apply
Routine Physical Exam
Exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury
Medicare doesn't encompass the routine concrete; it's prohibited past statute, but Medicare covers some elements of a routine concrete nether the IPPE, the AWV, or other Medicare benefits
Patient pays 100% out-of-pocket
AWV/IPPE FAQs
Accelerate Care Planning (ACP) every bit an Optional AWV Chemical element
Alcohol Misuse Screening & Counseling
Annual Wellness Visit (AWV)
Bone Mass Measurements
Cardiovascular Disease Screening Tests
Colorectal Cancer Screening
Counseling to Prevent Tobacco Use
Low Screening
Diabetes Screening
Diabetes Self-Management Training (DSMT)
Flu, Pneumococcal, & Hepatitis B Shots and their Administration
Glaucoma Screening
Hepatitis B Screening
Hepatitis C Screening
Human Immunodeficiency Virus (HIV) Screening
Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
IBT for Obesity
Initial Preventive Physical Test (IPPE)
Lung Cancer Screening
Medical Nutrition Therapy (MNT)
Medicare Diabetes Prevention Program (MDPP)
Prolonged Preventive Services
Prostate Cancer Screening
Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests
Screening for Sexually Transmitted Infections (STIs) & High Intensity Behavioral Counseling (HIBC) to Prevent STIs
Screening Mammography
Screening Pap Tests
Screening Pelvic Exam (includes a clinical breast examination)
Ultrasound Screening for Intestinal Aortic Aneurysm (AAA)
Notice more information on each Medicare preventive service in the MLN'due south Medicare Preventive Services educational tool.
No. The IPPE isn't a routine physical that some older adults may get periodically from their physician or other qualified Non-Physician Practitioner (NPP). The IPPE is an introduction to Medicare and covered benefits and focuses on health promotion, illness prevention, and detection to help patients stay well. We encourage providers to inform patients near the AWV and perform such visits. The SSA explicitly prohibits Medicare coverage for routine physical examinations.
No. The AWV isn't a routine physical that some older adults may get periodically from their physician or other qualified NPP. Medicare doesn't encompass routine physical examinations.
No. The IPPE and AWV don't include clinical laboratory tests, only yous may make advisable referrals for these tests as part of the IPPE or AWV.
No. Medicare waives both the coinsurance/copayment and the Medicare Part B deductible for the IPPE (HCPCS lawmaking G0402). Neither is waived for the screening electrocardiogram (ECG/EKG) (HCPCS codes G0403, G0404, or G0405).
No. Medicare waives the AWV coinsurance or copayment and the Medicare Part B deductible.
A patient who hasn't had an IPPE and whose initial enrollment in Medicare Function B began in 2020 is eligible for an IPPE in 2021 equally long as it's within 12 months of the patient'south commencement Medicare Part B enrollment constructive engagement.
We suggest providers check with their MAC for available options to verify patient eligibility. If you take questions, contact your MAC.
Medicare covers an AWV for all patients who aren't within 12 months afterward the eligibility date for their starting time Medicare Part B do good menstruation and who didn't have an IPPE or an AWV within the past 12 months. Medicare pays for but 1 IPPE per patient per lifetime and 1 additional AWV per yr thereafter.
More often than not, y'all may provide other medically necessary services on the aforementioned date as an AWV. The deductible and coinsurance or copayment apply for these other medically necessary and reasonable services.
AWV/IPPE: Medicare Diabetes Prevention Programme (MDPP) Expanded Model
CMS Roadmap Strategy to Fight the Opioid Crisis
MLN Matters® Article SE18004, Review of Opioid Utilise During the IPPE and the AWV
Reducing Opioid Misuse
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Early on detection saves lives. Encourage patients to get their preventive services.
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