Billing and Coding Essentials: The Annual Wellness Visit Will Help Increase Your Bottom Line


The implementation of the Affordable Care Act’s provisions for Annual Wellness Visits (AWV) has prompted primary care physicians to take a closer look at the law’s provisions. The Centers for Medicare & Medicaid Services (CMS) said the newly mandated Health Risk Assessment (HRA) is to be included as a part of the AWV beginning this year. Medicare beneficiaries have been entitled to an AWV since 2011, but ACA gave providers additional time to establish more specific guidelines.

Why Is This Important?

The logic behind the funding of an AWV/HRA by CMS is aimed at better management of chronic disease in order to achieve better outcomes for patients and reduce the costs of care.

The Dollars and Sense of It

The cost of providing healthcare has skyrocketed for most physicians, so every dollar counts. Billers and coders should take careful note of the AWVs. Providers and patients must be well informed and complete their respective components of the AWV/HRA. The circle must be complete to be accurately reimbursed. Everyone involved has a role to play to avoid snafus.

Nationally, average reimbursement from CMS carriers is generous:

  • First annual AWV service, G0438 = $172.18
  • Subsequent annual service, G0439 = $111.35/li>


If a family practitioner had a CMS panel of 200 patients and provided the first AWV (G0438) to each of them by 12/31/12, the practice would generate an additional $34,436.

Additionally, if in the second year, say 12/31/13, the same provider billed and coded to CMS on the panel of 200, the subsequent AWV – G0439, the prospective ROI would be $22,270.

The AWV comes with no out of pocket cost to the member, so the ROI in both examples is at full reimbursement. Not a bad return for a once a year visit.

Direct From CMS

The CMS’s postition on the AWV/HRA: “Pursuant to section 4103 of the Affordable Care Act of 2010 (ACA), the Centers for Medicare & Medicaid Services expanded coverage to allow for an Annual Wellness Visit (AWV) including personalized prevention plan services (PPPS) for an individual who is no longer within 12 months of the effective date of his/her first Medicare Part B coverage period, and has not received either an initial preventive physical examination (IPPE) or an AWV with the past 12 months. Medicare coinsurance and Part B deductibles do not apply”.

What Is an HRA?

The Health Related Assessment (HRA) component of the AWV is an evaluation tool designed to identify specific information pertaining to a patient’s health status, risk factors, and emergent health issues.

CMS requires the HRA to be completed either prior to, the beneficiary or as a component of the AWV, by a provider.

The HRA should take no longer than 20 minutes to complete and should include a personalized prevention plan, which has been added as a key piece of AWV.

The Nuts And Bolts

Codes: CMS has created two codes that Billing and Coding staff should acclimate themselves with in order to submit accurate claims for providing these service

  1. G0438 – Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit
  2. G0439 – Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit
  • G0438 is a once in a lifetime benefit, as it is the initial AWV for that member.
  • If a member saw another physician who provided the initial AWV of G0438, regardless that the member is new to you and this is your first time billing/coding for the AWV – you still must code it as the subsequent AWV with G0439.
  • CMS will pay for an Initial AWV – G0438, only after the first 12 months as a beneficiary has passed. During the first 12 months, the IPPE (Welcome to Medicare visit) should be coded and billed to CMS. The AWV could be payable by Medicare after the first year of enrollment and only if it has been more than 11 full months following the IPPE.
  • Medical necessity for the AWV/HRA has not been specifically established with a list of relevant diagnosis codes, so unless there is a change, providers would use a preventive diagnosis code.
  • CMS allows for a variety of adjunct services to be provided at the same time of service (TOS) as the AWV, such as a screening breast and pelvic exam and certain E&M services.  Additional information can be found in the CMS IOM, Publication 100-04, Chapter 12, Section and 30.6.2 to determine specific billing instructions.
  • CMS allows mid-level providers to record generated data at the AWV/HRA’s in a practice, including an RN – under CR 7079 for either new or established patients under the AWV They must be a licensed professional and their state practice act allows them to perform the services. The MD/DO or a non-physician practitioner must provide direct supervision of the service when billing under a Medicare provider number. The billing is under the entity providing the direct supervision.
  • Check if a member has had an AWV by going to: Centers for Medicare & Medicaid Services (CMS) Secure Net Access Portal (C-SNAP) displays this information.
  • If CMS is the Secondary Payer for a beneficiary – Code and Bill the AWV codes to the member’s primary insurance and then submit the charges to Medicare for secondary payment along with a copy of the remittance, unless it has an electronic crossover to CMS.

Word to the Wise

I realize that the AWV/HRA may appear as just another cross that billers, coders, and providers have to bear in the changes unleashed by the Affordable Care Act, but don’t be discouraged.  By providing beneficiaries the AWV/HRA, not only will your practice gain a significant source of additional revenue, you will be doing your part to help reduce health care costs long term, by accurately reporting chronic conditions and providing preventative care to a demographic that one day you will be a part of, too.

I don’t know about you, but I am expecting to receive the full suite of what CMS and Social Security has to offer me after working hard for many years.  Do your part and exercise due diligence: Bill, code and provide accurate and timely services as the AWV/HRA serves the greater good of the healthcare community overall.

Tools and Tips

My Brain Test Free AWV/HRA exams and packets for in office use. | Annual Wellness Cognitive Exam packet now available for health care providers. Includes standardized Annual Wellness Visit Exam Form and Personalized Prevention Plan Service template, also available as a (PDF). And here’s a doc version of an Annual Wellness Checklist

CMS Check out MLN Matters Number MM7079 for additional information and links to other Medicare resources on services that must be provided at the AWV and subsequent AWV.

Happy Coding!


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