Code Medicare’s Preventive Visits from Head to Toe

By Joyce Will, CPC

There are two types of annual wellness visits (AWVs): an initial visit (G0438 Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit) and a subsequent visit (G0439 Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit). These visits do not replace the “welcome to Medicare” visit (initial preventive physical exam (IPPE)) that has been covered since 2005.

Rather, they are in addition to the IPPE. The requirements for each of these services are very similar:

Service Name HCPCS Coverage Limits Required Elements
Welcome to Medicare Visit, IPPE G0402 Once in a lifetime – within the first 12 months of Medicare eligibility 1. Review and documentation of the patient’s medical and social history2. Review and documentation of patient’s potential risk factors for depression and/or other mood disorders3. Review and documentation of patient’s functional ability and level of safety4. Physical examination, including height, weight, BP, visual acuity, and BMI

5. End-of-life planning

6. Education, counseling, and referral (if necessary) based on the five items above

7. Education, counseling, and referral (brief written plan) for other preventive services

Screening EKG G0403 (global) G0404 (tracing only) G0405 (interp/report only) One time only (covered only in conjunction with IPPE)  
Ultrasound screening for AAA G0389 One time only – referral must come as a result of IPPE  
AWV, including PPPS, Initial G0438 Once in a lifetime – not within 12 months of Medicare enrollment (IPPE during this time) or within 12 months of IPPE 1. Establishment or update of the patient’s medical and family history2. Review of individual’s potential risk factors for depression and/or other mood disorders based on appropriate screening instrument3. Review and documentation of patient’s functional ability and level of safety based on direct observation or use of appropriate screening questions4. Physical examination, including height, weight, BP, BMI (or waist circumference), and other routine measurements appropriate based on history

5. Establishment of a list of current providers and suppliers involved in providing medical care to individual

6. Detection of any cognitive impairment

7. Establishment of a written screening schedule for the next five-10 years, as appropriate, based on USPSTF and ACIP recommendations, health status, screening history, and age-appropriate preventive services covered by Medicare

8. Establishment of a list of risk factors and conditions of which interventions are recommended or underway for the individual, including those identified through an IPPE and a list of treatment options and associated risks and benefits

9. Provision of personalized health advice to the individual and referral, as appropriate, to programs aimed at reducing identified risk factors including weight loss, physical activity, smoking cessation, fall prevention, and nutrition

AWV, including PPPS, subsequent G0439 Annually, but not within 12 months of initial visit (G0438) 1. Update of the patient’s medical and family history2. Update list of current providers and suppliers involved in providing medical care to individual3. Physical examination, including weight, BP, and other routine measurements appropriate based on history4. Detection of any cognitive impairment

5. Update written screening schedule for the next five-10 years, as appropriate, based on USPSTF and ACIP recommendations, health status, screening history, and age-appropriate preventive services covered by Medicare, established at initial visit

6. Update list of risk factors and conditions of which interventions are recommended or underway for the individual, including those identified through an IPPE and a list of treatment options and associated risks and benefits

7. Provision of personalized health advice to the individual and referral, as appropriate, to programs aimed at reducing identified risk factors including weight loss, physical activity, smoking cessation, fall prevention, and nutrition

 

IPPE and AWV services require very little physical examination, other than routine measurements. In contrast, if patients and physicians were asked to describe a “physical,” it likely would involve a head-to-toe examination and discussion of age-appropriate risk factors. Routine physicals, as described by CPT® 99381-99397, have never been covered under the Medicare program. Whether commercial payers cover preventive services depends entirely upon the individual patient’s plan coverage.

When the physician provides a problem-oriented service, or sick visit, with an IPPE or AWV, remember these guidelines:

  • New Patients: Do not bill both services together regardless of the insurance because the history and exam elements overlap and documentation can only be counted once. Both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services state, “a review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient.” New patients fit in this category. The IPPE and AWV also require patient past medical, family and/or social history. Counting work done once for two billed services is “double dipping.”
  • Established Patients: Documentation for the sick visit requires a chief complaint and history of present illness, with medically necessary exam and decision making for the problem being treated. Other history components are tied up in the requirements of the IPPE or AWV and would not count towards documentation of the sick visit.

Alert Patients What to Expect

Medicare patients expecting a complete physical exam when scheduled for a welcome to Medicare or AWV may be disappointed by the reality of the service. Because disappointment often translates to unfavorable satisfaction surveys, educate patients on exactly what the service they are requesting entails when they make their appointment.

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4 Responses to “Code Medicare’s Preventive Visits from Head to Toe”

  1. Gloria says:

    Can the physician take occult blood and lab work at either of these visits and bill for them?

  2. Dana says:

    G0438 #4 – Medicares guideslines does not mention “Physical Examination” it specifically states it is updating personal information, etc (not a “Head to Toe” exam). Can some one please clarify why this article is different than Medicare’s document on these codes.
    https://www.cms.gov/manuals/downloads/clm104c12.pdf

  3. Theresa says:

    Can 99214 be billed w/99397??

  4. Wanda says:

    Can code 95974 be billed with code 99215?

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