Last Modified: 7/17/2024
Location: FL, PR, USVI
Business: Part B
An annual wellness visit (AWV) is covered for all Medicare beneficiaries who:
• Are not within 12 months after the effective date of their first Medicare Part B coverage period and
• Have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months.
Effective for dates of service (DOS) on and after January 1, 2024 social determinants of health (SDOH) risk assessment has been added as an optional element:
• The billing HCPCS code is G0136.
• Add modifier -33 to an SDOH (HCPCS G0136), performed on the same day as the AWV to waive copayment and deductible.
• Note: Per MM13486, the implementation date for modifier 33, to be billed with G0136, is October 7, 2024.
• G0136 is covered once a year with copayment and deductible waived.
• Added information about community health integration (CHI) initiating visit
• The AWV can be an optional CHI initiating visit when the provider identifies any unmet SDOH needs that prevent the patient from doing the recommended personalized prevention plan.
G0438 -- Initial visit (once in a lifetime)
G0439 -- Subsequent visit (annually)
G0468 -- Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit including an IPPE or AWV and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV
99497 -- Advance care planning (ACP) 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
99498 -- ACP 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)
G0136 -- Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes
Deductible, coinsurance and modifiers
G0438 and G0439:
• No copayment, coinsurance, or deductible
G0468:
• You must provide an AWV or IPPE with a standard bundle of services available to all patients
• No copayment, coinsurance, or deductible
99497 and 99498:
• Deductible and coinsurance for ACP is only waived when furnished as an optional element of an AWV, which requires:
• Billing with modifier -33 (Preventive Service) on the same claim as an AWV
• Furnishing on the same day and by the same provider as the AWV
• Once in a lifetime for G0438 (first AWV).
• Annually for G0439 (subsequent AWV) and G0468 (AWV in FQHC)
• Annually for optional 99497, 99498
ACP is treated as an optional preventive service when furnished with an AWV.
• Practitioners may provide ACP outside of the AWV multiple times in a year, but the practitioner must document a change in the beneficiary’s health for each additional service in a year.
• When providing ACP outside the AWV, the beneficiary is responsible for the deductible and coinsurance.
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