what is ppps initial visit

Medicare Wellness Visits Back to MLN Print November 2023 Updates

What’s Changed?

• Added information about monthly chronic pain management and treatment services
• Added information about checking for cognitive impairment during annual wellness visits
• Added information about Social Determinants of Health Risk Assessments as an optional element of annual wellness visits

Quick Start

The Annual Wellness Visits video helps you understand these exams, as well as their purpose and claim submission requirements.

Medicare Physical Exam Coverage

Initial Preventive Physical Exam (IPPE)

Review of medical and social health history and preventive services education.

✔ New Medicare patients within 12 months of starting Part B coverage

✔ Patients pay nothing (if provider accepts assignment)

Annual Wellness Visit (AWV)

Visit to develop or update a personalized prevention plan and perform a health risk assessment.

✔ Covered once every 12 months

Routine Physical Exam

Exam performed without relationship to treatment or diagnosis of a specific illness, symptom, complaint, or injury.

✘ Medicare doesn’t cover a routine physical

✘ Patients pay 100% out-of-pocket

Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health :

• Health Equity Technical Assistance Program
• Disparities Impact Statement

Communication Avoids Confusion

As a health care provider, you may recommend that patients get services more often than we cover or that we don’t cover. If this happens, help patients understand they may have to pay some or all costs. Communication is key to ensuring patients understand why you’re recommending certain services and whether we cover them.

Initial Preventive Physical Exam

The initial preventive physical exam (IPPE), also known as the “Welcome to Medicare” preventive visit, promotes good health through disease prevention and detection. We pay for 1 IPPE per lifetime if it’s provided within the first 12 months after the patient’s Part B coverage starts.

1. Review the patient’s medical and social history

At a minimum, collect this information:

• Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments)
• Current medications, supplements, and other substances the person may be using
• Family history (review the patient’s family and medical events, including hereditary conditions that place them at increased risk)
• Physical activities
• Social activities and engagement
• Alcohol, tobacco, and illegal drug use history

Learn information about Medicare’s substance use disorder (SUD) services coverage .

2. Review the patient’s potential depression risk factors

Depression risk factors include:

• Current or past experiences with depression
• Other mood disorders

Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. APA’s Depression Assessment Instruments has more information.

3. Review the patient’s functional ability and safety level

Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the patient’s:

• Ability to perform activities of daily living (ADLs)
• Hearing impairment
• Home and community safety, including driving when appropriate

Medicare offers cognitive assessment and care plan services for patients who show signs of impairment.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), blood pressure, balance, and gait
• Visual acuity screen
• Other factors deemed appropriate based on medical and social history and current clinical standards

5. End-of-life planning, upon patient agreement

End-of-life planning is verbal or written information you (their physician or practitioner) can offer the patient about:

• Their ability to prepare an advance directive in case an injury or illness prevents them from making their own health care decisions
• If you agree to follow their advance directive
• This includes psychiatric advance directives

6. Review current opioid prescriptions

For a patient with a current opioid prescription:

• Review any potential opioid use disorder (OUD) risk factors
• Evaluate their pain severity and current treatment plan
• Provide information about non-opiod treatment options
• Refer to a specialist, as appropriate

The HHS Pain Management Best Practices Inter-Agency Task Force Report has more information. Medicare now covers monthly chronic pain management and treatment services .

7. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them to treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

8. Educate, counsel, and refer based on previous components

Based on the results of the review and evaluation services from the previous components, provide the patient with appropriate education, counseling, and referrals.

9. Educate, counsel, and refer for other preventive services

Include a brief written plan, like a checklist, for the patient to get:

• A once-in-a-lifetime screening electrocardiogram (ECG), as appropriate
• Appropriate screenings and other covered preventive services

Use these HCPCS codes to file IPPE and ECG screening claims:

Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment

Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv

* Section 60.2 of the Medicare Claims Processing Manual, Chapter 9 has more information on how to bill HCPCS code G0468.

Report a diagnosis code when submitting IPPE claims. We don’t require you to use a specific IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an IPPE when performed by a:

• Physician (doctor of medicine or osteopathy)
• Qualified non-physician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist)

When you provide an IPPE and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

CPT only copyright 2022 American Medical Association. All rights reserved.

IPPE Resources

• 42 CFR 410.16
• Section 30.6.1.1 of the Medicare Claims Processing Manual, Chapter 12
• Section 80 of the Medicare Claims Processing Manual, Chapter 18
• U.S. Preventive Services Task Force Recommendations

No. The IPPE isn’t a routine physical that some patients may get periodically from their physician or other qualified non-physician practitioner (NPP). The IPPE is an introduction to Medicare and covered benefits, and it focuses on health promotion, disease prevention, and detection to help patients stay well. We encourage providers to inform patients about the AWV during their IPPE. The Social Security Act explicitly prohibits Medicare coverage of routine physical exams.

No. The IPPE and AWV don’t include clinical lab tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.

No. We waive the coinsurance, copayment, and Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening electrocardiogram (ECG) (HCPCS codes G0403, G0404, or G0405).

A patient who hasn’t had an IPPE and whose Part B enrollment began in 2023 can get an IPPE in 2024 if it’s within 12 months of the patient’s Part B enrollment effective date.

We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, find your MAC’s website .

Annual Wellness Visit Health Risk Assessment

The annual wellness visit (AWV) includes a health risk assessment (HRA). View the HRA minimum elements summary below. A Framework for Patient-Centered Health Risk Assessments has more information, including a sample HRA.

Perform an HRA

• You or the patient can update the HRA before or during the AWV
• Consider the best way to communicate with underserved populations, people who speak different languages, people with varying health literacy, and people with disabilities
• Demographic data
• Health status self-assessment
• Psychosocial risks, including, but not limited to, depression, life satisfaction, stress, anger, loneliness or social isolation, pain, suicidality, and fatigue
• Behavioral risks, including, but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (for example, seat belt use), and home safety
• Activities of daily living (ADLs), including dressing, feeding, toileting, and grooming; physical ambulation, including balance or fall risks and bathing; and instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, transportation, shopping, managing medications, and handling finances

1. Establish the patient’s medical and family history

At a minimum, document:

• Medical events of the patient’s parents, siblings, and children, including hereditary conditions that place them at increased risk
• Use of, or exposure to, medications, supplements, and other substances the person may be using

2. Establish a current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure
• Other routine measurements deemed appropriate based on medical and family history

4. Detect any cognitive impairments the patient may have

Check for cognitive impairment as part of the first AWV.

Assess cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others. Consider using brief cognitive tests, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Alzheimer’s and Related Dementia Resources for Professionals has more information.

5. Review the patient’s potential depression risk factors

6. Review the patient’s functional ability and level of safety

• Ability to perform ADLs

7. Establish an appropriate patient written screening schedule

Base the written screening schedule on the:

• Checklist for the next 5–10 years
• United States Preventive Services Task Force and Advisory Committee on Immunization Practices (ACIP) recommendations
• Patient’s HRA, health status and screening history, and age-appropriate preventive services we cover

8. Establish the patient’s list of risk factors and conditions

• A recommendation for primary, secondary, or tertiary interventions or report whether they’re underway
• Mental health conditions, including depression, substance use disorders , suicidality, and cognitive impairments
• IPPE risk factors or identified conditions
• Treatment options and associated risks and benefits

9. Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs

Include referrals to educational and counseling services or programs aimed at:

• Fall prevention
• Physical activity
• Tobacco-use cessation
• Social engagement
• Weight loss

10. Provide advance care planning (ACP) services at the patient’s discretion

ACP is a discussion between you and the patient about:

• Preparing an advance directive in case an injury or illness prevents them from making their own health care decisions
• Future care decisions they might need or want to make
• How they can let others know about their care preferences
• Caregiver identification
• Advance directive elements, which may involve completing standard forms

Advance directive is a general term that refers to various documents, like a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. The Advance Care Planning fact sheet has more information.

We don’t limit how many times the patient can revisit the ACP during the year, but cost sharing applies outside the AWV.

11. Review current opioid prescriptions

• Review any potential OUD risk factors
• Provide information about non-opioid treatment options

12. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them for treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

13. Social Determinants of Health (SDOH) Risk Assessment

Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and ensure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate.

1. Review and update the HRA

2. Update the patient’s medical and family history

At a minimum, document updates to:

3. Update current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including those added because of the first AWV personalized prevention plan services (PPPS), and any behavioral health providers.

• Weight (or waist circumference, if appropriate) and blood pressure

5. Detect any cognitive impairments patients may have

Check for cognitive impairment as part of the subsequent AWV.

6. Update the patient’s written screening schedule

Base written screening schedule on the:

7. Update the patient’s list of risk factors and conditions

• Mental health conditions, including depression, substance use disorders , and cognitive impairments
• Risk factors or identified conditions

8. As necessary, provide and update patient PPPS, including personalized health advice and appropriate referrals to health education or preventive counseling services or programs

9. Provide advance care planning (ACP) services at the patient’s discretion

10. Review current opioid prescriptions

11. Screen for potential substance use disorders (SUDs)

12. Social Determinants of Health (SDOH) Risk Assessment

Preparing Eligible Patients for their AWV

Help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment:

• Medical records, including immunization records
• Detailed family health history
• Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
• Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists

Use these HCPCS codes to file AWV claims:

Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

Report a diagnosis code when submitting AWV claims. We don’t require you to use a specific AWV diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an AWV if performed by a:

• Medical professional (including health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of medical professionals directly supervised by a physician

When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV, and G0439 is for subsequent AWVs. Don’t bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. We deny these claims with messages indicating the patient reached the benefit maximum for the time period.

Medicare telehealth includes HCPCS codes G0438 and G0439.

ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a patient to discuss their health care wishes and medical treatment preferences if they become unable to communicate or make decisions about their care. At the patient’s discretion, you can provide the ACP during the AWV.

Use these CPT codes to file ACP claims as an optional AWV element:

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Report a diagnosis code when submitting an ACP claim as an optional AWV element. We don’t require you to use a specific ACP diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

We waive both the Part B ACP coinsurance and deductible when it’s:

• Provided on the same day as the covered AWV
• Provided by the same provider as the covered AWV
• Billed with modifier 33 (Preventive Service)
• Billed on the same claim as the AWV

We waive the ACP deductible and coinsurance once per year when billed with the AWV. If we deny the AWV billed with ACP for exceeding the once-per-year limit, we’ll apply the ACP deductible and coinsurance .

We apply the deductible and coinsurance when you deliver the ACP outside the covered AWV. There are no limits on the number of times you can report ACP for a certain patient in a certain period. When billing this service multiple times, document changes in the patient’s health status or wishes about their end-of-life care.

SDOH is important in assessing patient histories; in assessing patient risk; and in guiding medical decision making, prevention, diagnosis, care, and treatment. In the CY 2024 Medicare Physician Fee Schedule final rule , we added a new SDOH Risk Assessment as an optional, additional element of the AWV. At both yours and the patient’s discretion, you may conduct the SDOH Risk Assessment during the AWV.

Use this HCPCS code to file SDOH Risk Assessment claims as an optional AWV element:

Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes

Report a diagnosis code when submitting an SDOH Risk Assessment claim as an optional AWV element. We don’t require you to use a specific SDOH Risk Assessment diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

The implementation date for SDOH Risk Assessment claims is July 1, 2024. We waive both the Part B SDOH Risk Assessment coinsurance and deductible when it’s:

We waive the SDOH Risk Assessment deductible and coinsurance once per year when billed with the AWV.

If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when you deliver the SDOH Risk Assessment outside the covered AWV.

AWV Resources

• 42 CFR 410.15
• Section 140 of the Medicare Claims Processing Manual, Chapter 18

No. The AWV isn’t a routine physical some patients may get periodically from their physician or other qualified NPP. We don’t cover routine physical exams.

No. We waive the coinsurance, copayment, and Part B deductible for the AWV.

We cover an AWV for all patients who’ve had Medicare coverage for longer than 12 months after their first Part B eligibility date and who didn’t have an IPPE or AWV within those past 12 months. We cover only 1 IPPE per patient per lifetime and 1 additional AWV every 12 months after the date of the patient’s last AWV (or IPPE). Check eligibility to find when a patient is eligible for their next preventive service.

Generally, you may provide other medically necessary services on the same date as an AWV. The deductible and coinsurance or copayment applies for these other medically necessary and reasonable services.

You have different options for accessing AWV eligibility information depending on where you practice. Check eligibility to find when a patient is eligible for their next preventive service. Find your MAC’s website if you have specific patient eligibility questions.

Know the Differences

An IPPE is a review of a patient’s medical and social health history and includes education about other preventive services .

• We cover 1 IPPE per lifetime for patients within the first 12 months after their Part B benefits eligibility date
• We pay IPPE costs if the provider accepts assignment

An AWV is a review of a patient’s personalized prevention plan of services and includes a health risk assessment.

• We cover an annual AWV for patients who aren’t within the first 12 months after their Part B benefits eligibility date
• We cover an annual AWV 12 months after the last AWV’s (or IPPE’s) date of service
• We pay AWV costs if the provider accepts assignment

A routine physical is an exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.

• We don’t cover routine physical exams, but the IPPE, AWV, or other Medicare benefits cover some routine physical elements
• Patients pay 100% out of pocket

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CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Medical Billing Blog

Billing and coding for the medicare annual wellness visits.

Services provided during all three types of AWVs involve establishing and/or updating patient records with essential vital signs, personal and family health status and history, medications and indications.  Physicians can help patients get ready for their AWV by encouraging them to come prepared with the following information:

• Medical Records, including immunization records
• Family health history with as much detail as possible
• Full list of current medications--including calcium, vitamins and over-the-counter products–and dosage and frequency for each
• Full list of current providers and suppliers involved in providing care

  Three Visits With Three Sets Of Requirements

  1.)    G0402 – Initial preventive physical examination, face to face with patient, this service is for new Medicare beneficiaries and must be performed within the first 12-months of Medicare Enrollment. This is not a physical exam, even though the physician does measure and record basic vitals, but the patient is also eligible for an EKG screening (electrocardiograph--G0403-G0405) and aortic aneurism ultrasound (AAU) if they meet certain guidelines for these services.  Often referred to as the “Welcome to Medicare Physical,” this benefit is only payable once during an enrollee’s lifetime.  If a patient does not take advantage of the Welcome To Medicare visit within their first year of Medicare enrollment, they lose the Welcome Visit benefit, and it can never be recovered.

For more details on EKG and AAU screenings , please visit the CMS website.  

2.)    G0438 – Annual Wellness visit: Initial visit, includes a personalized prevention plan of care (PPPS).  Once a patient has had the Welcome to Medicare Visit, 11 full months must pass before the patient is eligible for the Annual Wellness Visit, Initial Visit.  This visit can be preformed any time in the patient’s life, but can only be performed once .  If a patient did not have the “Welcome to Medicare” visit within that first year of Medicare enrollment, they are still eligible for the Initial Annual Wellness Visit at any point in their life.

At the Initial Annual Wellness Visit, the health care provider will perform all of the key components of the visit, and record and discuss findings with the patient.  Together, the provider and patient will devise a wellness plan and screening schedule intended to aid in maintaining or improving the health of the patient.  The key elements include:

• Establishment of the patient’s medical/family history
• Measurement of the patient’s height, weight, BMI (body mass index), blood pressure, and other routine measurements as deemed appropriate, based on patient’s medical and family history
• List of current providers and suppliers (diabetic supplies, etc) that are regularly providing care
• Detection of any cognitive impairments the patient may have
• Review of a patient’s potential risk factors for depression
• Review of the patient’s functional ability and level of safety, based on direct observation of the patient
• Establishment of written screening schedule for the patient, such as a checklist for the next 5-10 years
• Establishment of a list of risk factors and conditions against which primary, secondary, or tertiary interventions are recommended or underway for the patient, including any mental health conditions or any such risk factors or conditions that have been indentified through an initial preventive physical exam (IPPE), and a list of treatment options and their associated risks and benefits
• Provision of personalized health advice to the patient 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.

3.)    G0439 – Annual Wellness visit: Subsequent visit, includes personalized prevention plan (PPPS).   After 11 full months have passed since the patient’s Initial Annual Wellness Visit ( G0438), the patient becomes eligible for the “Subsequent” Wellness Visit(s).  The patient can request this visit every year, after a full 11 months have passed .  The key elements performed during the Subsequent Annual Wellness Visits include:

• Updating of the patient’s medical/family history
• Updating of the list of the patient’s current medical providers and suppliers that are regularly involved in providing medical care to the patient, as was developed in the first Annual Wellness Visit (AWV), providing PPPS
• Updating of the patient’s written screening schedule as developed at the first AWV, providing PPPS
• Updating of the list of risk factors and conditions of which primary, secondary, or tertiary interventions are recommended or underway for the patient, as was developed at the first AWV, providing PPPS.
• Furnishing appropriate personalized health advice to the patient and a referral, as appropriate, to health education or preventive counseling services or programs

These preventive wellness benefits were designed by CMS to follow a logical progression in managing the health of Medicare enrollees.  There is a well-defined “introductory” visit, which is the Welcome To Medicare Visit, G0402; followed 11 months later by the Initial Annual Wellness Visit, G0438, and the Subsequent Annual Wellness Visits, G0439, to follow at intervals of roughly one year.  It’s actually a much simpler progression than it often gets credit for, and, once understood, proves to be a valuable tool for enabling providers to collaborate effectively with their mature patients on improving and maintaining good health for a longer life. You can find a summary of the requirements of all Medicare Wellness Visits on the CMS website.

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by Lucy Lamboley

An essential element of the Medicare annual wellness visit (AWV) is the personalized prevention plan, sometimes referred to as the personalized prevention plan of service or PPPS. During the annual wellness visit, you are expected to create or update the patient's Medicare personalized prevention plan. This requirement is clearly stated, both in the regulations and AWV HCPCS codes descriptors, and yet it is often neglected. When the PPPS is overlooked, the potential ramifications are significant. Providers run the risk of experiencing claims denials, needing to return payments if shortcomings are discovered during audits, and reducing the value of the AWV and PPPS to patients.

As Medicare.gov notes , the personalized prevention plan is designed to help prevent disease and disability based on a patient's current health and risk factors. Studies, such as one conducted by the Harvey L. Neiman Health Policy Institute that was published in Preventive Medicine , found that annual wellness visits, coupled with completion of the personalized prevention plan, increase the likelihood that patients will receive preventative health services. These include undergoing mammograms, prostate cancer screenings, colon cancer screenings, and receiving the influenza vaccine.

As Danny Hughes, one of the study's authors, states in a news release, "Promoting preventive care among the Medicare population is essential to enable the elderly to stay healthy, avoid or delay the onset of disease, and live productive lives."

Medicare Personalized Prevention Plan Tips

Follow these five recommendations to improve the development of a personalized prevention plan.

1. Understand the requirements. 

If providers want to avoid the risks discussed above, they must ensure the PPPS is completed and done so properly during each AWV. Here is a summary of the core requirements:

• Produce a written preventive screening and services plan for the next 5-10 years, based on the following:
• recommendations of the United States Preventive Services Task Force; 
• recommendations of the Advisory Committee on Immunization Practices (a committee within the U.S. Centers for Disease Control and Prevention);
• individual’s health risk assessment (HRA); 
• individual’s health status;
• individual’s screening history; and 
• appropriate, Medicare-covered preventive services. 
• List patient-specific risk factors and conditions, including those identified during administration/update of the HRA, which would benefit from interventions or are already being addressed through interventions. Include mental health risks and conditions. 
• Provide personalized health advice for these health concerns and risks. 
• Identify any referrals to specialists, counseling services, and other programs

Within the regulations is the expectation that patients will be "furnished" with the personalized prevention plan and advice. While furnished is not specifically defined, it has been interpreted to mean either a physical copy of the PPPS handed to the patient upon completion of the AWV or a copy placed into a patient's active health portal account. A faxed copy is also considered acceptable if completed soon after the visit and only to address mistakes or exigencies but should never be considered part of standard workflow.

What is important to note that is that providing a copy of the HRA is not enough to qualify as a PPPS, nor is giving generic health advice that fails to speak to a patient's specific conditions. While you can provide a copy of the HRA and include generic health advice, they must be part of the more robust and patient-specific PPPS.  

2. Help patients come to you prepared

Make sure patients know the information they should bring to the annual wellness exam that will help you assemble or update a complete Medicare personalized prevention plan. If patients come unprepared, you will likely need to spend more time discussing and documenting these details and may be faced with information gaps that hinder your ability to produce an effective plan.

Information patients should come prepared with includes:

• Names of all current physicians and their specialties
• List of all current self-management and community-based interventions, including those for mental health conditions 
• Current medical records, including immunization and screening details
• Family health history

Also, ask patients to think in advance about any issues they want to discuss during their visit. This will help you better personalize the PPPS and advice you share.

3. Understand language needs

Another potential hindrance to completing the Medicare personalized prevention plan — and doing so in a timely fashion — is a language barrier. As a Centers for Medicare & Medicaid Services (CMS) report notes , an analysis of the 2014 American Community Survey (ACS), which is conducted by the U.S. Census Bureau, approximately 4 million or 8% of the 52 million beneficiaries are individuals with limited English proficiency. Spanish is overwhelmingly the most common language spoken by Medicare beneficiaries with limited English proficiency, with over half identifying Spanish as the language they speak at home.

When your staff schedule a patient's Medicare annual wellness visit, they should determine whether the patient is an individual with limited English proficiency. If so, they should work to identify the individual's preferred language and bring this to your attention. Knowing this information in advance will allow you to take the necessary steps to address such a barrier that can contribute to misunderstandings between you and the patient as well as extend the time spent on the visit. Such a step may include using language services.

4. Be prepared with a range of referral sources

As CMS notes , the personalized prevention plan should consist of referrals to educational and counseling services or programs aimed at community-based lifestyle interventions that can help reduce health risks and promote self-management and wellness. These include fall prevention, nutrition, physical activity, tobacco-use cessation, weight loss, and cognition.

To ensure the most personalized care possible, providers should have a list of options for referral sources for preventive and diagnostic services — internal and external to your organization — and work with patients to select the sources that make the most sense for their individual needs. Note: Providers are required by law to make all necessary referrals. 

Issues to consider when making these choices are as follows:

• Accessibility. How easily can the patient get to the service or program? Factors to consider might include traveling distance, parking, and mass transit. Another consideration: hours for services of programs and whether they align with the patient's schedule. Any obstacles to accessibility will likely decrease the probability that the patient follows through on the referral.
• Language. As previously discussed, language can be a significant barrier to care. If a patient requires services in a language other than English, the referred service or program should be able to accommodate this need.
• Availability. Services and programs can come and go. Make sure you are working off as current of a list of referral options as possible. If a patient pursues a service or program only to find that it no longer exists or has moved to an inaccessible location, you may not know the patient failed to follow through on the referral until the next Medicare annual wellness visit.
• Cost. A patient's ability to cover the expenses of services or programs must be a careful consideration, especially considering reports highlighting the financial struggles of many Medicare patients. Costs that need to be considered are not just any fees associated with the services or programs themselves, but also those expenses associated with transportation (e.g., gas, tolls, parking fees, taxis), childcare, and pet care.

5. Invest in technology

There is a significant amount of information to cover and document in the development of a Medicare personalized prevention plan. The more time spent on personalized prevention plan creation , the higher the cost of each annual wellness visit. In addition, documentation shortcomings can lead to coding and billing errors as well as increase audit risks.

Fortunately, providers can invest in solutions that will help automate plan development, which can reduce time to complete annual wellness visits — potentially enough to fit more patients into your schedule — while also decreasing the chance of documentation mistakes. 

One option we think you'll like is Prevounce. With the Prevounce platform, providers can streamline creation and completion of a compliant AWV with PPPS. Prevounce automates pre-visit outreach via text or email, helping patients come better prepared for their appointment and reducing the time spent by providers gathering background information. The platform simplifies the HRA, giving providers detailed information that allows them to ask more targeted questions that can help truly personalize the PPPS. Prevounce includes a personalized prevention plan creation feature that automates the plan and scheduling of preventive services. It even helps streamline billing and coding, so you receive fast, appropriate payments. Schedule a no-risk live demo now !

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Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS)

The Affordable Care Act provides for an Annual Wellness Visit (AWV), including Personalized Prevention Plan Services (PPPS) for Medicare beneficiaries as of January 1, 2011. CR 7079 provides the requirements for the AWV, which are summarized in this article. Make sure billing staff are aware of these services and how to bill for them.

Download the Guidance Document

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: February 15, 2011

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

Confusion about the Medicare annual wellness visit

Since its debut last year, the Medicare annual wellness visit (AWV) has been an apparent source of ongoing confusion. That point was driven home to me again this week after I reviewed some Medicare claims data for this service.

As a reminder, there are two codes related to the AWV:  G0438 (includes a personalized prevention plan of service, initial visit) and G0439 ( includes a personalized prevention plan of service, subsequent visit). As the descriptors imply, the initial AWV, should precede a subsequent AWV, and at least 11 months should have elapsed since the month of the initial AWV before a subsequent AWV can be performed and billed.

Both services became Medicare benefits effective Jan. 1, 2011. In 2011, Medicare paid for G0439 (subsequent AWV) more than 50,000 times. Given the timing of the two services and given that a Medicare beneficiary could not receive G0438 (initial AWV) before Jan. 1, 2011, it is not clear how or why any claims for a subsequent AWV (G0439) would have been processed in 2011.

I suspect that G0439 was being reported in 2011 because of confusion regarding its relationship to the Initial Preventive Physical Exam (IPPE, also known as the "Welcome to Medicare Visit"), code G0402. As noted in " When A Medicare Annual Wellness Visit Follows a Welcome to Medicare Physical ," FPM , May/June 2012, "The initial annual wellness visit must take place before a subsequent annual wellness visit in order to establish the required components that will be updated at subsequent visits. The initial annual wellness visit must occur no earlier than the same month of the year following the IPPE." In other words, the inital AWV follows an IPPE and a subsequent AWV follows an initial AWV.

Why the Medicare contractors reimbursed for G0439 in 2011 is a mystery. Apparently, they do not have the capacity or edits in place to recognize when a subsequent AWV is billed erroneously instead of an initial AWV.

For physician practices, this is more than just a matter of miscoding. It is also a matter of lost revenue. Medicare's average allowance for G0438 is $166; for G0439, it is approximately $111. That means that every time you bill G0439 when you should have billed G0438, you are leaving about $55 on the table. Maybe that's why the Medicare carriers were happy to process G0439 claims in 2011.

For more information on the AWV, check out the FPM Topic Collection on Medicare Annual Wellness Visits . 

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