What Is the CPT Code for a Medicare Annual Wellness Visit?

The Medicare Annual Wellness Visit (AWV) serves as a valuable opportunity for beneficiaries to engage proactively in their health management. This visit focuses on preventive care, aiming to identify potential health risks early and develop strategies to maintain well-being. By emphasizing a forward-looking approach to health, the AWV helps individuals and their healthcare providers work together to address concerns before they become more serious. It represents a commitment to comprehensive health planning rather than reactive treatment of illnesses.

Components of an Annual Wellness Visit

An Annual Wellness Visit is structured to provide a thorough, personalized assessment of a patient’s health status and future needs. The visit typically begins with a Health Risk Assessment (HRA), which gathers information about a person’s health conditions, risk factors, and social determinants of health. This assessment helps to tailor the subsequent components of the visit to the individual’s specific circumstances.

Following the HRA, the healthcare provider will review and update the patient’s medical and family history, ensuring all relevant health information is current. A comprehensive list of current providers and medications is compiled, which helps to coordinate care and prevent potential drug interactions. Functional ability and safety are also assessed, covering areas such as hearing, vision, and the risk of falls.

A key part of the AWV includes a cognitive function screening to detect any signs of cognitive impairment. The visit also involves routine measurements such as height, weight, body mass index (BMI), and blood pressure. Based on these assessments, a personalized prevention plan is developed or updated, outlining appropriate screenings, immunizations, and health education services for the upcoming year. This plan is designed to empower individuals with actionable steps for maintaining their health.

Eligibility for the Annual Wellness Visit

Eligibility for the Medicare Annual Wellness Visit is tied to a beneficiary’s enrollment in Medicare Part B. To qualify for an initial AWV, an individual must have been enrolled in Medicare Part B for at least 12 months.

Furthermore, there is a specific waiting period after receiving an Initial Preventive Physical Examination (IPPE), often referred to as the “Welcome to Medicare” visit. An individual cannot receive an AWV within 12 months of their IPPE. This prevents duplication of preventive services during the initial period of Medicare enrollment.

After the initial AWV, beneficiaries are eligible for subsequent Annual Wellness Visits once every 12 months. This consistent frequency allows for ongoing monitoring of health risks and regular updates to the personalized prevention plan.

Specific CPT Codes for the Annual Wellness Visit

Healthcare providers use specific Current Procedural Terminology (CPT) codes, also known as HCPCS codes, to bill Medicare for Annual Wellness Visits. These codes precisely identify the type of service rendered, which is essential for proper reimbursement and compliance with Medicare regulations. The two primary codes for the AWV are G0438 and G0439.

Code G0438 is designated for the “Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit.” This code is used exclusively for a beneficiary’s very first Annual Wellness Visit. A beneficiary can only have one G0438 billed in their lifetime.

Code G0439 is used for the “Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit.” This code applies to all Annual Wellness Visits that occur after the initial G0438 visit. The G0439 code can be billed annually, provided at least 11 full months have passed since the last AWV.

Medicare Coverage and Associated Costs

Medicare Part B provides comprehensive coverage for the Annual Wellness Visit. When an AWV is performed by a healthcare provider who accepts Medicare assignment, the service is covered at 100%. This means beneficiaries typically incur no out-of-pocket costs, such as deductibles, copayments, or coinsurance, for the AWV itself. This full coverage encourages individuals to utilize this important preventive service.

It is important to understand that this 100% coverage applies specifically to the components that are part of the Annual Wellness Visit. If additional services are provided during the same visit that are not considered part of the AWV, separate charges may apply. Examples of such services include laboratory tests, electrocardiograms (EKGs), or addressing new health concerns that require diagnosis and treatment. These additional services may be subject to standard Medicare Part B deductibles and copayments, as they fall outside the scope of the preventive wellness visit. Providers are generally expected to inform beneficiaries if additional services will be performed that may incur separate costs.