Maximize Billing Opportunities for the Medicare AWV

The Medicare Annual Wellness Visit (AWV) is not subject to incident-to billing. It can be provided by a physician assistant, nurse practitioner, or clinical nurse specialist without the assistance of an MD or DO.  It cannot be billed incident-to by the MD or DO under their NPI number.

The practice may decide to have the pre-visit Health Risk Assessment  along with the required physical vitals (blood pressure, height , weight, pulse ) collected by a medical assistant (MA) or licensed nurse practitioner (LPN) and then ready for review by the MD or DO. CMS allows this preliminary collection of data by an MA or LPN under the supervision of an MD or DO, or even a PA or NP.

The billing authority then reviews the data and makes any medical decisions, usually in 5 minutes to 15 minutes, and bills under their appropriate NPI.

It would not be really cost effective for the provider - whether an MD, DO, PA, or NP - to spend the whole time collecting the data, when they only need to provide the medical decisions related to the visit.

This may open up the opportunity for practices to provide AWVs on days when the MD or DO is not in the office on certain days during the week.  The MA or LPN could consolidate the HRA data and present it to the PA or NP for review and medical decisions before billing.

Since the AWV can generate a minimum of $166, the practice revenue would be about $141 at 85 percent for the G0438 code. There is also the opportunity for billing the annual FOBT colon cancer screen for about $22 and the annual depression and alcohol screens for $34 at about $17 each.

Some practices may choose to schedule these AWVs on days when the PA or the NP is available, but not the MD, so that significant revenue is generated for these benefits on a day when the practice may not normally generate the same revenue as days when the MD or DO is in the office.

I have even seen instances when a practice employed a part-time NP or PA to come in certain days just to provide the AWV. If efficient scheduling is created, an NP could provide six AWVs, for example, with screens and generate almost $200 each, $1,200 per day, or over $60,000 annually for one day per week.  This is a significant return on investment for the practice.

Think about scheduling AWVs efficiently and coordinating PAs or NPs to provide them. Your practice and your patients could both benefit.