Medical Practice Management
Jan 16

Medicare Recovery Audit Finding: Annual Wellness Visit

Medicare pays for an initial Annual Wellness Visit (AWV), per beneficiary per lifetime. All subsequent wellness visits must be billed as a subsequent Annual Wellness Visit (AWV). The HCPCS codes to be used in billing the AWVs are: G0438 – Annual Wellness Visit, Initial Visit, per beneficiary per lifetime, and G0439 – All subsequent wellness visits must be billed as a subsequent AWV.

Example 1: A 76 year old male received an Initial Annual Wellness Visit on March 2, 2011. The physician billed HCPCS Code G0438 (Initial Annual Wellness Visit) and was paid $195.63. On February 7, 2013, the same beneficiary received another Annual Wellness Visit.

Auditor Finding: The provider billed HCPCS Code G0438 (Initial Annual Wellness Visit) for the 2013 visit, even though the patient had already received the Initial Annual Wellness Visit on date of service March 2, 2011. This resulted in an overpayment.

Example 2: A 75 year old male received an Initial Annual Wellness Visit on March 25, 2011. The physician billed HCPCS Code G0438 (Initial Annual Wellness Visit) and was paid $183.38. On June 14, 2012, the same beneficiary received another Annual Wellness Visit.

Auditor Finding: The provider billed HCPCS Code G0438 (Initial Annual Wellness Visit) for the 2012 visit when the patient had already received the Initial Annual Wellness Visit on date of service March 25, 2011. This resulted in an overpayment.

How Providers Can Avoid These Problems

You should understand the differences in coding claims for the Initial Annual Wellness Visit and any subsequent wellness visits. Ensure that your billing staffs understand the correct use of HCPCS Codes for Initial and Subsequent Annual Wellness Visits in order to bill the proper codes. Here is a resource that may be helpful:

The "Medicare Claims Processing Manual," Chapter 12, Section 30.6.1.1(C) provides the Medicare coverage guidelines for AWVs and that portion of the manual is available at

http://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/downloads/clm104c12.pdf.

About Reed Tinsley, CPA

As a top advisor to physicians, I help increase practice profits by delivering hands-on, expert medical accounting/tax support, practice counsel, and revenue-building strategies. Read more →