(Medicare Claims Processing Manual)

1. It is performed by a health professional;   2. It is furnished to an eligible beneficiary who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and he/she has not received either an IPPE or an AWV providing PPPS within the past 12 months.  See Pub. 100- 02,Medicare Benefit Policy Manual, chapter 15, section 280.5, for detailed policy regarding the AWV, including definitions of:  (1) detection of cognitive impairment, (2) eligible beneficiary, (3) establishment of, or an update to, an individuals medical/family history, (4&5) first and subsequent AWVs providing PPPS, (6) health professional, and, (7) review of an individuals functional ability/level of safety.   140.1 - Healthcare Common Procedure Coding System (HCPCS) Coding for the AWV  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  The HCPCS codes listed below were developed for the AWV benefit effective January 1, 2011, for individuals whose initial enrollment is on or after January 1, 2011.   G0438 -  Annual wellness visit; includes a personalized prevention plan of service (PPPS); first visit   G0439 -  Annual wellness visit; includes a personalized prevention plan of service (PPPS); subsequent visit   140.2 - A/B MAC (B) Billing Requirements  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  Effective for dates of service on and after January 1, 2011, A/B MACs (B) shall recognize HCPCS codes G0438 and G0439 shown above in section 140.1 for billing AWVs.  The type of service (TOS) for each of the new codes is 1.  AWV services are paid under the  Medicare Physician Fee Schedule (MPFS).   For further instructions regarding practitioner reporting of HCPCS codes G0438 and G0439 under different clinical scenarios, see chapter 12, sections 30.6.1.1 and 100.1.1 of this manual.  140.3 - A/B MAC (A) Billing Requirements (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  The A/B MAC (A) will pay for AWV services only when submitted on one of the following types of bill (TOBs): 12X, 13X, 22X, 23X, 71X, 77X, and 85X.  Type of facility and setting determines the basis of payment:    For services performed on a 12X TOB and 13X TOB, hospital inpatient Part B and hospital outpatient, payment shall be made under the MPFS.    For services performed in a skilled nursing facility, TOB 22X and TOB 23X, make payment based on the MPFS.    For services performed on a 71X TOB, rural health clinic (RHC) or 77X TOB, Federally Qualified Health Center (FQHC), payment is made based on an all -inclusive rate and the AWV does not qualify for separate payment with another encounter.    For services performed on an 85X TOB, Critical Access Hospital (CAH), pay based on reasonable cost.   For services performed on an 85X TOB, CAH Method II, payment is based on the MPFS.   For inpatient or outpatient services in hospitals in Maryland, make payment according to the Health Services Cost Review Commission.   Only CAHs paid under the optional method are paid for professional services for the AWV (in addition to the facility payment) when those charges are reported under revenue codes 096X, 097X, or 098X.   140.4 - Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC) Special Billing Instructions  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  Beginning with dates of service on or after January 1, 2011, if an AWV is provided in an RHC or FQHC, the professional portion of the service is billed to the A/B MAC (A) using TOBs 71X and 77X, respectively, and must include HCPCS code G0438 or G0439.  De ductible and coinsurance do not apply.  140.5 - Coinsurance and Deductible  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04 -04-11)  Sections 4103 and 4104 of the Affordable Care Act provide for a waiver of Medicare coinsurance/copayment and Part B deductible requirements for the AWV effective for services furnished on or after January 1, 2011.  140.6 - Common Working File (CWF) Edits  (Rev. 2575, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)  Effective for claims with dates of service on and after January 1, 2011, CWF shall reject:    AWV claims for G0438 when a previous (first) AWV, HCPCS code G0438, is paid in history regardless of when it occurred.    AWV claims when a previous AWV, G0438 or G0439, is paid in history within the previous 12 months.   Beginning January 1, 2011, AWV claims when a previous IPPE, HCPCS code G0402, is paid in history within the previous 12 months.    AWV claims (G0438 and G0439) billed for a date of service within 12 months after the effective date of a beneficiarys first Medicare Part B coverage period.   The following change shall be effective for claims processed on or after April 1, 2013. Typically, when a preventive service is posted to a beneficiarys utilization history, separate entries are posted for a professional service (the professional claim for the delivery of the service itself) and a technical service (the institutional claims for a facility fee).  However, in the case of AWV services, since there is no separate payment for a facility fee, the AWV claim will be posted as the professional service only, regardless of whether it is paid on a professional claim or an institutional claim.   140.7 - Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Advance Beneficiary Notices (ABNs)  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Messages for A/B MACs (A) and (B):   When paying claims for an AWV, A/B MACs (A) and (B) shall use the following Medicare Summary Notices (MSNs):   MSN:  18.25: -  Your Annual Wellness Visit has been approved.  You will qualify for another Annual Wellness Visit 12 months after the date of this visit.   Spanish Version Su Visita Anual de Bienestar ha sido aprobada. Usted tendr derecho a otra Visita Anual de Bienestar 12 meses despus de la fecha de esta visita.  When denying claims for a first AWV, HCPCS G0438, when a first AWV, HCPCS G0438, is already paid in history, A/B MACs (A) and (B) shall use the following messages:   MSN 20.12: -  This service was denied because Medicare only covers this service once a lifetime.   Spanish Version:  Este servicio fue negado porque Medicare slo cubre este servicio una vez en la vida.   CARC 149: Lifetime benefit maximum has been reached for this service/benefit category.   RARC N117:   This service is paid only once in a patient's lifetime .  Group Code -  PR  When denying claims for a subsequent AWV, HCPCS G0439, because a previous AWV, HCPCS G0438 or G0439, is paid in history within the past 12 months, A/B MACs (A) and (B) shall use the following messages:  MSN 18.26:  This service was denied because it occurred too soon after your last covered Annual Wellness Visit.  Medicare only covers one Annual Wellness Visit within a 12 month period.   Spanish Version:  Este servicio fue negado porque ocurri antes del perodo de 12 meses de su ltima Visita Anual de Bienestar.  Medicare slo paga por una Visita Anual de Bienestar dentro de un perodo de 12 meses.   CARC 119:  Benefit maximum for this time period or occurrence has been reached.   RARC N130 Consult plan benefit documents/guidelines for information about restrictions for this service.   Group Code -  PR  When denying claims for an AWV, HCPCS G0438 or G0439, because an IPPE, HCPCS G0402, is paid in history with the past 12 months, A/B MACs (A) and (B) shall use the following messages:   (New) MSN  18.27:  This service was denied because it occurred too soon after your Initial Preventive Physical Exam.   Spanish Version:  Este servicio fue negado porque ocurri demasiado pronto despus de su examen fsico preventivo inicial.   CARC 119:  Benefit maximum for this time period or occurrence has been reached.   RARC N130:  Consult plan benefit documents/guidelines for information about restrictions for this service.   Group Code -  PR  When denying claims for an AWV, HCPCS G0438 or G0439, because the services were rendered within the first 12 months after the effective date of a beneficiarys first Medicare Part B coverage period, A/B MACs (A) and (B) shall use the following messages:   (New)  MSN  18.24:  This service was denied.  Medicare doesnt cover an Annual Wellness Visit within the first 12 months of your Medicare Part B coverage.  Medicare does cover a one -time initial preventive physical exam (Welcome to Medicare physical exam) within the fir st 12 months of your Medicare Part B coverage.   Spanish Version:  Este servicio fue negado.  Medicare no cubre la Visita Anual de Bienestar durante los primeros 12 meses de su inscripcin a la Parte B de Medicare.  Medicare cubre un examen fsico preventivo ("Bienvenido a Medicare") durante los primeros 12 meses de su inscripcin a la Parte B de Medicare.  CARC 26:  Expenses incurred prior to coverage   RARC N130: Consult plan benefit documents/guidelines for information about restrictions for this service.   Group Code -  PR  140.8  Advance Care Planning (ACP) as an Optional Element of an Annual Wellness Visit (AWV)  (Rev.  10456, Issued: 11- 13-20, Effective: 04 -01-21, Implementation: 04- 05-21)  For services furnished on or after January 1, 2016, Advance Care Planning (ACP) is treated as a preventive service when furnished with an AWV.  The Medicare coinsurance and Part B deductible are waived for ACP when furnished as an optional element of an AWV.  The codes for the optional ACP services furnished as part of an AWV are 99497 (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 professional; first 30 minutes, face -to-face with the patient, family member(s) and/or surrogate;) and an add- on code 99498 (each additional 30 minutes (List separately in addition to code for primary procedure)).  When ACP services are provided as a part of an AWV, practitioners would report CPT code 99497 (and add- on CPT code 99498 when applicable) for the ACP services in addition to either of the AWV codes (G0438 or G0439).  Note: ACP services are payable in hospice (Types of Bill 081x or 082x) when not part of the AWV when the services are performed by attending physicians that are employed by, or under arrangement with, the hospice.   150 - Counseling to Prevent Tobacco Use  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)