Medicare Wellness Exam

UPDATE:  CMS has published a revision to the requirements of the Annual Wellness Visit.  On January 10, 2011, CMS removed the provision for voluntary advance care planning.  No other changes to the requirements were made.  Note that this does not prevent a physician from discussing this with a patient, it only deletes it as a requirement for the Annual Wellness Visit.


There are a number of interesting provisions of the Affordable Care Act being implemented via the Physician Fee Schedule (PFS)final rule. The implementation date of most of the provisions is January 1, 2011. Although the PFS is a fee for service (FFS) or Original Medicare rule, most of these have an impact on our network, either for their FFS patients, or their MA members. For MA members, you should contact your contracted health plan for information regarding the Annual Wellness Visit. 






Over the next few weeks, we'll be posting some of these provisions in the PFS. 


Original Medicare excludes screening and preventative services.  Over the past few years, laws have been passed allowing a number of these screening services as exceptions to Medicare law--for example, screenings for colon cancer, screening mammography, a "Welcome to Medicare" physical, etc. 


The Affordable Care Act (ACA) § 4403 has added another set of preventative services to Medicare-- an Annual Wellness Visit (AWV), including Personalized Prevention Plan Services (PPPS) for Medicare beneficiaries as of January 1, 2011. Based on this revision,  CMS amended sections 411.15(a)(1) and 411.15 (k)(15) of 42 CFR (list of examples of routine physical examinations excluded from coverage)  This amendment’s expanded coverage now allows payment for an AWV, including PPPS, for an individual who is no longer within 12 months of the beneficiary's  Medicare Part B coverage date and has not received either an initial preventive physical examination (IPPE-the "Welcome to Medicare physical") or an AWV within the past 12 months. No Medicare coinsurance or Part B deductibles apply to the AWV. 

 Who Can Provide the Annual Wellness Visit  with PPPS?

1. A physician who is a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Social Security Act (the Act); or,
2. A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act); or,
3. A medical professional (including a health educator, registered dietitian, or nutrition professional or other licensed practitioner) or a of such medical professionals, working under the direct supervision (as defined in 42 CFR 410.32(b)(3)(ii)) of a physician (a doctor of medicine or osteopathy) 

The services required for an AWP with PPPS are slightly different depending on whether this is the first AWP with PPPS, or a subsequent AWP with PPS.  Note that these requirements may be changed (enhanced) at the direction of the Secretary, or through the National Coverage Determination process.

What is Included in an Initial AWV with PPPS?

• Establishment of an individual’s medical/family history.
• Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.
• Measurement of an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history.
• Detection of any cognitive impairment that the individual may have as defined in this section. Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations.

• Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations.
• Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
• Establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
• Furnishing of personalized health advice to the individual 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, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
• Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process.

What is Included in a Subsequent AWV/PPPS?

• An update of the individual’s medical/family history.
• An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing PPPS.
• Measurement of an individual’s weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individual’s medical/family history.
• Detection of any cognitive impairment that the individual may have as defined in this section.
• An update to the written screening schedule for the individual as that schedule is defined in this section, that was developed at the first AWV providing PPPS.
• An update to the list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, as that list was developed at the first AWV providing PPPS.
• Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs.
• Any other element(s) determined by the Secretary through the NCD process.

Note: Voluntary Advanced Care Planning refers to verbal or written information regarding an individual’s ability to prepare an advance directive in the case where an injury or illness causes the individual to be unable to make health care decisions and whether or not the physician is willing to follow the individual’s wishes as expressed in an advance directive.

Codes for AWV/PPPS

Two new HCPCS codes have been developed for these services:

• G0438 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit, (Short descriptor – Annual wellness first)
• G0439 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit, (Short descriptor – Annual wellness subseq) will be implemented
• Effective for services on or after January 1, 2011, FFS Medicare contractors (Medicare Adminstrative Contractors, Medicare Intermediaries and Medicare Carriers) will pay claims containing these codes provided the requirements for coverage and eligibility are met.

Edited 1/20/2011