Corporate

March 1, 2013

Annual Wellness Visits (AWVs) and Initial Preventive Physical Examinations (IPPEs) versus "Routine Examinations"

Medicare may cover two specialized physical examination services for eligible beneficiaries: the Initial Preventive Physical Examination (IPPE) and an Annual Wellness Visit (AWV).  When eligible for Medicare reimbursement, these services are covered at no cost to beneficiaries; coinsurance and deductible do not apply.  There are specific required elements and coverage criteria for both IPPEs and AWVs. 

In general, Medicare does not pay for "routine examinations." These services are designated as status N in the Medicare Physician Fee Schedule Database (MPFSDB) and are never reimbursed by Medicare. It is important to note that these CPT codes are not appropriate codes for submitting AWV or IPPE services.

Examination Type Procedure Code Tips
"Routine examination" CPT codes 99391-99397
  • Never reimbursed by Medicare
Initial Preventive Physical Examination (IPPE) HCPCS code G0402
  • One-time service
  • Within first 12 months of beneficiary's Medicare effective date
  • 7 required components
Annual Wellness Visit (AWV): initial HCPCS code G0438
  • May be covered once
  • 10 required components
Annual Wellness Visit (AWV): subsequent HCPCS code G0439
  • May be covered once per year
  • 8 required components

Initial Preventive Physical Examination (IPPE)

As part of the Affordable Care Act, Medicare provides coverage for an IPPE for patients who have been enrolled in Medicare for less than one year.  It is a one-time service, intended to help provide an introduction to insurance coverage, benefits, and give appropriate screening for disease detection and preventive promotion of health. The IPPE must be performed within the first 12 months after the effective date of the beneficiary's Medicare Part B coverage.

An IPPE includes the following seven components:

  • A review of the beneficiary's medical and social history
  • Review of the beneficiary's potential risk factors for mood disorders
  • Review of the beneficiary's functional ability and level of safety
  • An examination
  • End-of-life planning
  • Education, counseling, and referral based on the previous five components
  • Education, counseling, and referral for other preventive services

Annual Wellness Visit (AWV)

As part of the Affordable Care Act, Medicare provides coverage for an AWV for patients who are enrolled in Medicare.  This service may be covered as often as once per year. There are two specific types of AWV: initial and subsequent. 

Required elements for the initial AWV are:

  • A self-reported health risk assessment
  • Establishment of the beneficiary's medical/family history
  • Review of the beneficiary's potential risk factors for mood disorders
  • Review of the beneficiary's functional ability and level of safety
  • A health assessment within the office
  • Establishment of current providers and suppliers of service
  • Detection of any cognitive impairment that the beneficiary may have
  • Establishment of a written screening schedule for the beneficiary
  • Establishment of a list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended for the beneficiary
  • Furnishing of personalized health advice to the beneficiary, and a referral for further care, if appropriate

The subsequent AWV visit will be updating the patient's past history as established during the initial visit, as well as a new assessment to establish any needed additional treatment.  This is a shorter established service.  Required elements for subsequent AWVs are:

  • Update of the self-reported risk assessment
  • An update of the beneficiary's medical/family history
  • A health assessment within the office
  • Update of the list of current providers and suppliers of service
  • Detection of any cognitive impairment that the beneficiary may have
  • Update of the written screening schedule for the beneficiary
  • Update of the list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended for the patient
  • Furnishing of personal health advice to the beneficiary, and a referral for further care, if appropriate

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