By Christine Moore, CPC -- There seems to be some confusion out there from both physician offices and patients as to what is included in the Medicare Wellness Visits.  Office staff should be familiar with codes G0402, G0438, and G0439 to be able to explain to patients the purpose and scope of these visits.  Medicare coverage includes three different types of Wellness Visits that are offered to all enrollees, but these visits do not include a routine physical checkup.  They are intended to be a meeting between physician and patient to discuss current health status, and to devise a plan for maintaining good health, setting a schedule for preventive health screenings, and treating or stabilizing chronic ailments.  Medicare beneficiaries are eligible to receive the services associated with the Wellness Visits at no charge to the patient, with no copay or deductible due for the Annual Wellness Visit (AWV) itself, but if other services are provided during the course of the AWV, the patient is responsible for any copay or deductible applicable to those extra services.  Together, the three types of wellness visits are designed to establish and maintain regular contact between patient and physician, to ease communication about health and wellness issues, and to provide a basis for regular updating of patient records with regard to overall health.  Each type of visit is indicated at a specific point during the term of the patient’s coverage under Medicare, and there are specific guidelines for time periods during which each visit is payable.

Services provided during all three types of AWVs involve establishing and/or updating patient records with essential vital signs, personal and family health status and history, medications and indications.  Physicians can help patients get ready for their AWV by encouraging them to come prepared with the following information:

• Medical Records, including immunization records
• Family health history with as much detail as possible
• Full list of current medications--including calcium, vitamins and over-the-counter products–and dosage and frequency for each
• Full list of current providers and suppliers involved in providing care

 Three Visits With Three Sets Of Requirements

 1.)    G0402 – Initial preventive physical examination, face to face with patient, this service is for new Medicare beneficiaries and must be performed within the first 12-months of Medicare Enrollment. This is not a physical exam, even though the physician does measure and record basic vitals, but the patient is also eligible for an EKG screening (electrocardiograph--G0403-G0405) and aortic aneurism ultrasound (AAU) if they meet certain guidelines for these services.  Often referred to as the “Welcome to Medicare Physical,” this benefit is only payable once during an enrollee’s lifetime.  If a patient does not take advantage of the Welcome To Medicare visit within their first year of Medicare enrollment, they lose the Welcome Visit benefit, and it can never be recovered.

For more details on EKG and AAU screenings, please visit the CMS website. 

2.)    G0438 – Annual Wellness visit: Initial visit, includes a personalized prevention plan of care (PPPS).  Once a patient has had the Welcome to Medicare Visit, 11 full months must pass before the patient is eligible for the Annual Wellness Visit, Initial Visit.  This visit can be preformed any time in the patient’s life, but can only be performed once.  If a patient did not have the “Welcome to Medicare” visit within that first year of Medicare enrollment, they are still eligible for the Initial Annual Wellness Visit at any point in their life.

At the Initial Annual Wellness Visit, the health care provider will perform all of the key components of the visit, and record and discuss findings with the patient.  Together, the provider and patient will devise a wellness plan and screening schedule intended to aid in maintaining or improving the health of the patient.  The key elements include:

1. Establishment of the patient’s medical/family history
2. Measurement of the patient’s height, weight, BMI (body mass index), blood pressure, and other routine measurements as deemed appropriate, based on patient’s medical and family history
3. List of current providers and suppliers (diabetic supplies, etc) that are regularly providing care
4. Detection of any cognitive impairments the patient may have
5. Review of a patient’s potential risk factors for depression
6. Review of the patient’s functional ability and level of safety, based on direct observation of the patient
7. Establishment of written screening schedule for the patient, such as a checklist for the next 5-10 years
8. Establishment of a list of risk factors and conditions against which primary, secondary, or tertiary interventions are recommended or underway for the patient, including any mental health conditions or any such risk factors or conditions that have been indentified through an initial preventive physical exam (IPPE), and a list of treatment options and their associated risks and benefits
9. Provision of personalized health advice to the patient and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management or community-based lifestyle interventions to reduce health risks, and promote self-management and wellness.

3.)    G0439 – Annual Wellness visit: Subsequent visit, includes personalized prevention plan (PPPS).  After 11 full months have passed since the patient’s Initial Annual Wellness Visit (G0438), the patient becomes eligible for the “Subsequent” Wellness Visit(s).  The patient can request this visit every year, after a full 11 months have passed.  The key elements performed during the Subsequent Annual Wellness Visits include:

1. Updating of the patient’s medical/family history
2. Measurement of the patient’s height, weight, BMI (body mass index), blood pressure, and other routine measurements as deemed appropriate, based on patient’s medical and family history
3. Updating of the list of the patient’s current medical providers and suppliers that are regularly involved in providing medical care to the patient, as was developed in the first Annual Wellness Visit (AWV), providing PPPS
4. Detection of any cognitive impairments the patient may have
5. Updating of the patient’s written screening schedule as developed at the first AWV, providing PPPS
6. Updating of the list of risk factors and conditions of which primary, secondary, or tertiary interventions are recommended or underway for the patient, as was developed at the first AWV, providing PPPS.
7. Furnishing appropriate personalized health advice to the patient and a referral, as appropriate, to health education or preventive counseling services or programs

These preventive wellness benefits were designed by CMS to follow a logical progression in managing the health of Medicare enrollees.  There is a well-defined “introductory” visit, which is the Welcome To Medicare Visit, G0402; followed 11 months later by the Initial Annual Wellness Visit, G0438, and the Subsequent Annual Wellness Visits, G0439, to follow at intervals of roughly one year.  It’s actually a much simpler progression than it often gets credit for, and, once understood, proves to be a valuable tool for enabling providers to collaborate effectively with their mature patients on improving and maintaining good health for a longer life. You can find a summary of the requirements of all Medicare Wellness Visits on the CMS website.