Medicare Annual Wellness Visits: A Guide to Benefits, Payments

What is bundled, paid from referral, and separately reimbursed per a CMS schedule?

There are three delineations for wellness benefits in the Medicare Annual Wellness Visit (AWV):

1. Bundled - Required actions reimbursed inclusively for G0438 and G0402 wellness visits. These are generally brief questions or observations described as review, advise, refer, and detect.

They include:

• Detection of any cognitive impairment

• Review of functional ability

• Review of potential risk for depression

• Referral and advice for weight loss, exercise, smoking cessation, fall prevention, and nutrition

2. Referred - Risk conditions discovered in wellness visits that are eligible for further action and reimbursement, mostly at future times. These can be reimbursed for specific in-house provider actions (not referrals) termed counseling and therapy.

They include: (no co-pay / average annual rates)

• G0389 - $110 - Abdominal Aortic Aneurysm (AAA) screen
(only if referred by condition from G0402, once in lifetime during Part B first 12 months)

• G0436 - $13.60 - Tobacco Cessation counseling , 3 minutes to 10 minutes

• G0437 - $28.50 - Tobacco Cessation counseling , 15 minutes

• G0445 - $25.50 - High Intensity Behavioral Counseling to Prevent Sexually Transmitted Infections, 20 minutes to 30 minutes (two per year, requires lab test, see bulletin)

• G0446 - $25.50 - Annual Cardiovascular Disease Therapy, 15 minutes

• G0447 - $25.50 - Obesity Counseling, 15 minute sessions, 22 visit maximum if conditions met

These benefits may be provided when a patient answers positively on the Health Risk Assessment or displays conditions that indicate a need such as high blood pressure, overweight, etc. for cardiovascular disease or obesity.

3. Asymptomatic Screens or Tests - Annual or other CMS-scheduled benefits with no copay that may be provided at the AWV or other E&M encounter for all Part B eligible Medicare beneficiaries.

These include:

• G0328QW - $22.53 - FOBT annual colorectal screen (per CLIA waived test kit)

• G0442 - $17.20 - Annual Alcohol Screen, 15 minutes (per recognized national screen)

• G0443 - $25.50 - Alcohol Counseling, four (4) annually at 15 minutes, first allowed on same day if positive on G0442

• G0444 - $25.50 - Annual Depression Screen , 15 minutes (per recognized national screen)

EKG screens referred if needed at IPPE only (co-pay applies):
• G0403 – $19.03 - Complete screening w/12 leads, tracing, interpretation and report

• G0404 - $10.40 - Tracing only without interpretation and report

• G0405 - $8.62 - Interpretation and report only without tracing

For Women:
• G0101 - $42 - Screening pelvic/breast exam (annually for those at risk, 24 months for all others)

• Q0091 - $50 - Screening Pap smear (annually for those at risk, 24 months for all others

Physicians may choose to provide these reimbursable benefits per these choices:

• Standard protocol at time of wellness visits along with bundled actions

• Six-month intervals after wellness visits to establish updated conditions

• Any other interval separately or with any other encounter

The case for a six-month interval schedule may be that if patient answers negatively to the bundled review questions for alcohol or depression conditions at the time of the AWV or Initial Preventative Physical Examination (IPPE) visit, an additional annual screen at that time may not be relevant, although allowed by CMS. The situation may be that the patient then experiences a change in behavior and develops an alcoholic or depression condition which could then be detected and treated with a six-month interval schedule.

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