Annual Wellness Visit & Health Risk Assessment

G0438 (INITIAL) G0439 (SUBSEQUENT)

Annual wellness visit;

G0438             includes a personalized prevention plan of service (PPS), initial visit
G0439             includes a personalized prevention plan of service (PPS), subsequent visit

Explanation

Annual Wellness Visits (AWV) must include a Personalized Prevention Plan of Service (PPPS) and a Health Risk Assessment .

Coding Tips

• These annual wellness codes were created by Medicare, however they may be covered by other payers so check with individual payer policies.

• An AWV is not the same as an Initial Preventive Physical Examination (IPPE) which is also payable by Medicare. See Resource 480 for details by CMS on what to include for an IPPE.

• This is not the same as an annual routine physical checkup.

• There are no deductibles or co-pays for Medicare beneficiaries.

• Laboratory tests or other medical services are not part of the AWV, however, other medically necessary services may also be provided on the same date of service as an AWV. Be aware that deductibles, coinsurance/copayment for these services may apply.

• Covered providers:

• Physician (a doctor of medicine r osteopathy)

• Qualified non-pnysician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist)

• Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner)

• Team of such medical professionals who are working under the direct supervision of a physician (doctor of medicine or osteopathy)

Diagnoses

“Since CMS does not require a specific diagnosis code for the AWV, you may choose any appropriate diagnosis code. You must report a diagnosis code.”

Modifiers

• According to CMS, “When you provide a significant separately identifiable, medically necessary Evaluation and Management (E/M) service in addition to the AWV, Medicare may pay for the additional service. Report the Current Procedural Terminology (CPT) code with modifier 25.”

96160, 96161 HEALTH RISK ASSESSMENT

96160	Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument
96161	Administration of cargiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument

According to the PPACA, a Health Risk Assessment (HRA):

• must identify chronic diseases, injury risks, modifiable risk factors, and urgent health needs of the individual

• may be furnished through an interactive telephonic or web-based program

• may be offered during the encounter with a health care professional or through community-based prevention programs

• may be provided through any other means appropriate to maximize accessibility and ease of use by beneficiaries, while ensuring the privacy of the beneficiaries.

The patient’s health status and relevant conditions with risk adjusted HCCs (Hierarchical Condition Codes) assist CMS when tracking chronic conditions to help predict future healthcare needs, and is currently being used as a funding methodology. The idea is to risk adjust plan payments based on health status and demographic characteristics of an enrollee.

Coding Tips

• Risk Assessments during an AWV are collected from self-reported information from the beneficiary, taking no more than 20 minutes. The beneficiary information and required elements can be found on the CMS web site, including assessment information and counseling the beneficiary.

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