Annual Wellness Visits (AWVs) were created in 2011 by the Centers for Medicare and Medicaid Services (CMS) as a way for providers to focus on preventive care for patients. While these services are free to Medicaid beneficiaries, some patients may feel that AWVs are a waste of time. However, if done correctly, these visits can create valuable relationships between providers and patients, build trust, and lay out a roadmap for future screenings and referrals. Michael Cash, Senior Medical Practice Consultant with SVMIC, met with me to discuss more benefits, challenges, and important keys to successfully implementing AWVs into practice.
An AWV is an in-depth review of a patient’s overall health status. A clinician converses with the patient with preventive health goals in mind. “It’s kind of like doing maintenance on your car,” Michael says, “You go get your oil changed and schedule checkups at 50,000 and 100,000 miles to prolong the life of your car and prevent problems from arising in the future.” In the same way, engaging with a patient during an AWV helps to prepare for future medical issues that could occur later.
Types of AWVs
Wellness visits come in three varieties: the Initial Preventive Physical Examination (IPPE), the Initial Annual Wellness Visit (IAWV), and the Subsequent Annual Wellness Visit (SAWV). The IPPE is for patients who are new to Medicare. Patients can only receive this visit within the first 12 months of their enrollment. Otherwise, it’s too late. This first visit is about conducting a Health Risk Assessment (HRA), a screening questionnaire that provides the patient and doctor with the next steps upon completion. The HRA covers a few specific components and takes about 20 minutes to complete. An HRA can be taken at home, online, or over the phone as well, but CMS expects it to be finished prior to or during an AWV. The HRA generally asks patients about the following:
- Medical history, including previous and current health conditions (even those that run in the family)
- Demographics — age, gender, etc.
- Lifestyle — exercise regimen, eating habits, alcohol, and tobacco use
- Activities of daily living (ADLs) – dressing, bathing, feeding, toileting, grooming, etc.
- Emotional health — mood, stress, depression, etc.
- Physical health — weight, blood pressure, body mass index, heart rate
An IAWV is similar to an IPPE but differs in a few key ways. The IAWV is only available to patients after 11 months of Medicare enrollment. The IAWV includes an optional cognitive exam (clock test, memory test, etc.) and “end-of-life” planning. For new Medicare patients, even if they have completed an IPPE, they must still complete an IAWV. The IAWV is really meant to be a patient’s introduction to preventive care. Also completed through an HRA, this visit puts a patient in a good position for future health services to accommodate for any potential risks down the road. During this meeting, a patient and provider may schedule future exams, like colonoscopies or mammograms.
An SAWV is the annual follow-up visit to the IAWV. Eleven months after an IAWV, a patient can choose to attend these sessions to modify their preventive care plan based on any changes in their health. As a patient’s health changes over time, a doctor may use this visit to guide patients toward other Medicare preventive programs like Chronic Care Management (CCM), Behavioral Health Integration (BHI), or Remote Patient Monitoring (RPM). This is where the value of an AWV really comes into play: recommendations like these allow patients to receive opportunities to address their more specific health care needs, and doctors develop more streams of revenue fostered by Medicare coverage. Medicare generally covers the cost of these other services for enrollees.
Benefits of an AWV
Research shows that patients who complete visits like these are twice as likely to adhere to screening recommendations and are more satisfied overall with their health care. In other words, AWVs work! Overall, there are many benefits to implementing AWVs into your workflow as a provider.
As a provider, you’re getting ahead of the game with AWVs by doing your homework with the patient and preparing for their future based on your knowledge of the patient’s medical history. If providers have a preventive plan in place, they can save their care team time preparing for an unexpected visit. Instead, all visits are planned in advance (given any emergencies), and the patient is cared for as efficiently as possible.
Some payors are shifting their focus from fee-for-service reimbursement to fee-for-value. “Currently, providers are predominantly paid based on the number of patients they see,” Michael explains. “But now, some payors are are including value-based payments, which are usually identified by closing care gaps” [i.e., scheduling breast cancer screenings, colonoscopies, eye exams, etc.]. Closing care gaps helps mitigate or control chronic diseases that often result in more costly visits to the ER or hospital. AWVs provide the most effective solution for providers to close their payor gap and boost their revenue. “If providers work to close these gaps, some payors will provide additional financial incentives for reaching value-based targets.”
AWVs also provide benefits for patients. Patients who can’t afford to pay their medical bills will be glad to know that AWVs do not require a copay. Medicare covers one visit every 366 days. The Med Advantage plans cover patients for one visit per calendar year. “For patients,” Michael adds, “the AWVs focus on preventive measures that could prevent future problems from occurring. AWVs increase patients’ quality of life while decreasing health care expenditures.”
Some payors may also offer what is referred to as a “preferred provider status” for clinicians. “The idea for this is to steer patients to providers who are doing a better job of helping patients schedule these preventive visits,” Michael says. “Providers who look more favorable to insurance companies may benefit as the insurance companies try to steer patients to those providers that are more likely to schedule preventive exams,” he adds. More patients can mean more reimbursement.
Charge Codes and Reimbursement for AWVs
AWVs have specific codes that providers must pay attention to when logging their work. The main wellness codes are divided by age, the thought being that, as patients age, they may have different preventive plans. “Codes 99381–99387 are for new AWVs,” Michael explains. “99391–99397 are for established visits (patients that have had AWVs for a few years.” There are also Medicare G-codes that providers must enter correctly: G0402 is for Welcome to Medicare (IPPE) visits, G0438 is for visits from new patients after the initial visit (IAWV), and G0439 is for established visits (SAWV). “On average, the range of reimbursement for providers will be between $125–$150 (commercially) depending on the payor and the patient’s age,” Michael says.
Proper coding is essential not only to reimbursement for the provider but also for the patient’s insurance. AWVs are not head-to-toe physicals. In fact, most of the time, providers never do an exam with a patient during an AWV. “If a patient comes in for a wellness visit and complains that they have a cold, the visit then shifts to an office or treatment visit, not an AWV,” Michael says. Many patients may have a wellness benefit on their insurance that covers the full cost of a wellness visit, making it free to the patient. “If I go in saying I have a cold, the doctor then codes it as a ‘sick visit,’ not a wellness visit, and then my benefit is no longer in play. Now, I have to rely on my high-deductible health plan, and I’m responsible for the full value of my visit,” he says. Providers may try to code a sick visit as an AWV, and the payor will reject their claim and have the provider resubmit a claim under “sick visit.” Since AWVs often offer higher reimbursement numbers than sick visits, it is essential that providers properly code patients’ visits to ensure maximum financial reimbursement.
Overall, AWVs are designed to be effective ways for providers to connect with patients while also reducing the cost patients experience from unexpected hospital or ER visits. Proper coding is vital to ensuring that providers receive the maximum reimbursement possible for performing AWVs. While there may be some barriers that prevent providers from being able to incorporate AWVs into their practice fully, the benefits outweigh the setbacks. These visits are essential to a patient’s well-being and help providers shift their focus to a value-based, not volume-based, practice.