The Patient Protection and Affordable Care Act (PPACA) of 2010 added a new benefit for Medicare beneficiaries referred to as Annual Wellness Visits (AWV); HCPCS code G0438 for the initial visit and G0439 for each subsequent annual visit.

The initial AWV is similar to the current "Welcome to Medicare Visit", also called the Initial Preventive Physical Examination (IPPE). Beneficiaries who are newly enrolled in Medicare are still only eligible for the "Welcome to Medicare Visit" in the first year of their Medicare enrollment and not the new initial AWV. 

A Medicare beneficiary is eligible for the initial AWV if he/she has been enrolled in Medicare for longer than 12 months and has not received a "Welcome to Medicare" visit in the past 12 months.

As with the "Welcome to Medicare Visit", there are certain requirements that must be met and documented by the provider. As auditors, we should review the providers record to ensure the requirements are properly documented.

The AWV requires:

• Taking or updating the medical and family history;
• Establishing a list of current providers and suppliers of medical care;
• Height, weight, BMI calculation (or waist circumference), blood pressure, and "other routine measurements as deemed appropriate";
• Detection of any cognitive impairment that he may have by direct observation, with consideration of information from medical records, patient reports, concerns raised by family members;
• Review for the potential for depression based on use of an appropriate screening instrument;
• Review of his functional ability and level of safety, based on direct observation, or use of a screening questionnaire;
• Establishment of a written screening schedule, such as a checklist, for the next 5-10 years based on recommendations of the US Preventive Task Force and Advisory Committee on Immunization Practices, and the patient's health status, screening history, and age-appropriate covered Medicare services;
• Development of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway including mental health conditions or risk factors, or conditions identified through an previously performed Welcome to Medicare Visit (or this visit), and a list of treatment options and their associated risks and benefits; and
• Furnishing of personalized health advice and referral, as appropriate, to health education or preventive counseling programs aimed at reducing identified risk and improving self management including weight loss, smoking cessation, fall prevention, and nutrition.

Initially there was an end of life planning requirement, but this has recently been removed due to pressure from congress.

Keep in mind that many of these requirements can be met by the use of screening tools and questionnaires. In those cases they must be provided to the auditor for review along with the primary documentation.

You will also notice there is no requirement for examination of the patient other than essential vital signs. This has caused some confusion initially by providers as they feel a "head-to-toe" examination an important factor to any wellness evaluation. Even though the exam is not a requirement, providers are encouraged to perform an appropriate exam as part of sound medical care.

Medicare states that they will pay a physician for an AWV service and a medically necessary "sick visit" evaluation and management service furnished during a single beneficiary encounter. CMS believes however that "it would be uncommon for the two services to be provided to the same beneficiary on the same date". CMS also cautions that "the elements of the AWV must not be replicated in the E&M service". Providers must append modifier 25 (significant, separately identifiable service) to the medically necessary E&M service to be reimbursed for both services.

R. Kevin Townsend, CPC, CPMA, CMPE is a medical auditor and compliance consultant for DoctorsManagement as well as a co-author and instructor for the National Alliance of Medical Auditing Specialists. Kevin has an extensive background in practice management, coding, auditing, compliance, and reimbursement.  He has served as practice administrator for private, academic, and hospital owned practices in multiple specialties from primary care to general and pediatric surgery.  He also has special interest and experience with training, development, and implementation of both practice management and electronic medical record systems.  He is board certified by the MGMAs American College of Medical Practice Executives (CMPE), the American Academy of Professional Coders (CPC and CPMA).