A Medicare patient comes to her PCP’s office and says that today’s visit should be a “free visit” with no copays for her yearly physical. She states that this visit should be her Annual Wellness Visit. How should we code this?
Medicare recipients expect a physical exam, but a wellness visit is less of a physical exam and more of a discussion between a doctor and patient, reviewing a patient’s health status and risk factors based on past, family, and social history. The discussion may lead to referrals to specialists or for further tests. The patient must also complete a Health Risk Assessment form prior to the visit which helps the physician establish a personalized prevention plan for the patient. The visit will also provide a 5-10 year written screening plan. A subsequent Annual Wellness Visit can occur every 12 months.
All requirements of the AWV may be found in the Med Learn Matters document SE7079 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7079.pdf
The patient should understand that a physical which is performed for chronic conditions may be coded in addition to the Annual Wellness Visit, but the copay will apply. If the patient does not have any comorbidities, then a Preventative Medicine Visit can be billed with an ABN in addition to the Annual Wellness Visit and the payment would be the patient’s responsibility.
The codes for the Annual Wellness exam are G0349 for the initial exam and G0348 for the subsequent exam. The G0348 will not be paid unless the patient has received the initial exam prior to the subsequent examination. The Annual Wellness exam will not be paid within the first 12 months of the patient having Medicare. The patient would be eligible for an introductory physician visit called the Initial Preventative Physical Exam (IPPE) or Welcome to Medicare Exam. The patient would not be eligible for the initial Annual Wellness Exam until those 12 months have passed.
Therefore, when the patient comes in for her “free visit” you should explain the difference between an annual physical exam and the intent of the Medicare Wellness Visit.
February 2015 UConn Health Compliance Quandary