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Doctors ACO wants to clear the confusion about the Annual Medicare Visits

by in DoctorsACO
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Doctors ACO wants to clear the confusion about the Annual Medicare Visits. The Annual Wellness Visits (AWV) takes place with one’s primary care provider, and has NO deductibles, NO Coinsurance, and NO Copayments. An AWV includes:

  •          Establish patient's medical and family history.
  •          List of patient's current medical providers.


  •          List of all prescribed medications.
  •          Record height, weight, body mass index, and blood pressure.
  •          Mini-cognitive assessment.
  •          Establish or update a personal screening schedule for the next 5 to 10 years, include screenings appropriate for the general population and additional screenings that may be appropriate due to patient's risk factors.
  •          Establish a Personalized Prevention Plan of Service (PPPS)

The ‘Welcome to Medicare’ and AWV provides a snapshot of the patient’s current health and is a valuable preventative tool in that the can be used as a baseline for future yearly visits. The ‘Welcome to Medicare’ visit and AWV are not meant to replace your annual physical exam. An annual physical exam is much more extensive and may include further testing. 

There is much confusion regarding the differing levels of AWVs that can be performed.    

1.      The Annual physical exam (EM Code 92111-92115)

·         Most primary physicians conduct on their patients is an extensive history and physical exam and it is an office visit coded as EM Code 92111-92115. Annual Physical Examination Physical Exam for Patients Ages 65+ (99397).

This code is NOT on the Medicare website and we do not know if Medicare pays for it.


2.      A "Welcome to Medicare" Initial Preventive Physical Exam (IPPE) (G0402): You can get this introductory visit only within the first 12 months you have Part B, and is a onetime benefit. The patient will complete a questionnaire, called a “Health Risk Assessment (HRA),” as part of this visit and to aide in the reviewing process.  This visit includes a review of your medical and social history related to your health and education and counseling about preventive services, including certain screenings, shots, and referrals for other care, if needed. It also includes:

  • Height, weight, and blood pressure measurements
  • A calculation of your body mass index
  • A simple vision test
  • A review of your potential risk for depression and your level of safety
  • An offer to talk with you about creating advance directives.
  • A written plan letting you know which screenings, shots, and other preventive services you need. 

If you choose to perform an EKG during the IPPE visit, then you may bill G0403.  An EKG is not required to be performed during an IPPE, however it is recommended for overall evaluation of health.

A separate E/M visit (99201-99215) can be billed if indicated

·         IPPE is for health maintenance, not disease management

·         Use “-25 modifier” here on the E/M

This visit is covered one time. You don’t need to have this visit to be covered for yearly "Wellness" visits.

3.      An Annual “Wellness” visit (G0438):If the patient has had Part B for longer than 12 months but has not received a “Wellness” visit then they are eligible for this type of visit.  The patient will complete a HRA for this visit.  Answering these questions can help you and your patient develops a prevention plan of service (PPPS) to help them stay healthy and get the most out of their visit. It also includes:

  • A review of your medical and family history
  • Developing or updating a list of current providers and prescriptions
  • Height, weight, blood pressure, and other routine measurements
  • Detection of any cognitive impairment
  • Personalized health advice
  • A list of risk factors and treatment options for you
  • A screening schedule (like a checklist) for appropriate preventive services. 

This visit is covered once after the first initial 12 months of Part B has passed.  Every patient will have G0438 prior to G0439.

4.      A Subsequent "Wellness" visits (G0439): If the patient has had Part B for longer than 12 months, they are eligible for this visit to develop or update a personalized prevention help plan to prevent disease and disability based on the patient’s current health and risk factors. The patient will complete a HRA that will assist you in developing/updating their PPPS.

This visit is covered once every 12 months (11 full months must have passed since the last visit).

The Annual Wellness Visit can be performed with chronic disease office visit by adding the modifier 25 to EM Codes 92111-92115.

Compliance is vital when conducting AWVs.  Medicare requires 100% compliance on the AWV for reimbursement, this includes data collection AND performing “action” on the data collected.  You must take action upon the PPPS given to the patient and ensure that their testing is scheduled and met.  If you are not complying with all of these requirements, you could be in for a big surprise on an audit from CMS and they will retrieve all of the money you have collected, which could be $165 per AWV or more.

We like you to please audit your charts on all your patients that you have used G0438 or G0439 to avoid discrepancies identified by Medicare that would result in retrieval of payments.

Doctors ACO has asked multiple primary care physicians if they are implementing AWVs and we have concluded that these visits are not being conducted to guidelines or not being completed at all due to the non-compliance of Medicare regulations. 

Only 7% of Medicare beneficiaries are receiving this Annual Wellness Exam.

We, Doctors ACO, are reaching out to the area’s independent physicians and encouraging them to provide these visits for their Medicare patients in compliance with regulations.  To take further action, we will be hosting AWV learning sessions, open for all PCP’s and staff to attend, to educate you of these visits and how to successfully conduct them in your practice.





Subodh K. Agrawal, MD


Dr. Agrawal, has 32 years of experience in Internal Medicine, Sleep Medicine, Cardiovascular Disease, Cardiology, and Interventional Cardiology.He completed his Internal Medicine Residency from Emory University in Atlanta, Georgia and Interventional Cardiology Fellowship from the University of Alabama. He is published in numerous peer reviewed journals and is a frequent speaker at events.


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Guest Saturday, 26 May 2018

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