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12.02.2019

What is a Medicare Annual Wellness Visit?

by Jennifer Bresnick

The Medicare Annual Wellness Visit is a valuable opportunity to build strong relationships with patients, identify and document health risks, and complete a number of important preventive care activities. 

The Medicare Annual Wellness Visit (AWV) is a once-a-year, prevention-focused visit between a patient and a primary care provider. 

These visits allow providers and patients to update information about a patient’s health status, set shared goals for the year ahead, and close any gaps in care.  AWVs offer a dedicated time and place to focus on preventive care, long-term needs, and topics that might not be covered in other visits.

In addition to addressing clinical risks and existing issues, providers and patients can use the AWV to discuss emotional health, mental health, daily functioning, and any socioeconomic challenges that may have an impact on self-care and wellbeing.

“AWVs are a way of strengthening your connection to patients,” said Dr. Farzad Mostashari, Aledade CEO and co-founder, in a recent episode of The ACO Show podcast.  “Over the past few years, Medicare has really been trying to focus on primary care and has introduced a number of new payment codes for transitional care management, chronic care management, and the AWV.” 

“These are all meant to allow primary care to spend more time with the patient to do things that are meant to emphasize wellness instead of waiting until a person gets sick and treating them at that point.  That’s extremely important for success in the value-based care environment, particularly for accountable care organizations (ACOs),” he said.

Medicare beneficiaries can see numerous benefits when their primary care providers use AWVs to build patient-provider relationships, identify and document risks, and follow up on necessary services.  Providers also have the opportunity to strengthen revenue streams and ensure they are meeting their quality reporting goals.

What is involved in conducting an AWV?  Why do they matter so much? And how can these visits help patients and providers with their shared clinical and financial objectives?

What does an AWV look like?

AWVs are designed to create a space for real connection between individuals and their primary care providers, whether a patient is currently in good health or not.

For patients with fewer acute needs, these visits allow providers to establish a comprehensive baseline for rising risks, collect a complete patient history, and develop a personalized prevention plan for the future.

Patients with chronic diseases or other existing diagnoses can also benefit from these regular check-ins.  AWVs provide the time and space to ensure that providers are aware of any changes in health status or increase in disease burden over the past year.

Medicare uses three distinct HCPCS codes for the different types of AWVs available to Medicare Part B beneficiaries.  While the visit itself is very similar across the three categories, it is important for providers to know the differences in order to correctly bill for their services.

If the beneficiary is within their first 12 months of enrolling in Medicare, their first AWV should be billed as an Initial Preventive Physical Exam (IPPE) or Welcome to Medicare visit (G0402). 

If the patient has been a Medicare Part B beneficiary for more than 12 months, their first AWV should count as an initial AWV (G0438) instead.

The AWV starts with a Health Risk Assessment (HRA).  During or prior to the scheduled AWV, the patient must complete this assessment to evaluate their health risks, current conditions, and quality of life. 

At a minimum, the HRA includes:

  • Demographic data
  • A self-assessment of the individual’s health status
  • Information about psychosocial and behavioral risks
  • Information about daily living activities, including bathing and dressing, mobility inside and outside the home, money management, and medication management

The provider will also work with patients to collect other important data, including:

  • Personal and family medical history, including current diagnoses, allergies, and clinical risk factors
  • Height, weight, BMI, blood pressure, and other relevant routine measurements
  • A list of current providers, specialists, or suppliers
  • The use of medications, vitamins, over-the-counter products, and supplements
  • Risk or presence of depression, functional impairment, and cognitive impairment (the IPPE visit must also include a vision screening)

Once the provider has collected this information, they can document the individual’s risks appropriately, develop a personalized screening schedule for the patient, and discuss treatment options or lifestyle changes to address areas of heightened concern. 

Providers should share meaningful health advice that may include educational materials and referrals to counseling, community services, or other programs designed to encourage self-management and wellbeing. An AWV might include a discussion about advance care planning, but this element is not required.

This proactive, holistic approach to care is intended to forestall expensive and disruptive events such as unnecessary emergency department use or an avoidable hospitalization, said Mostashari. 

“We think of the AWV as a place to ask what's likely to get a person hospitalized over the next 12 months and what you can do today to prevent that,” he said.  “The AWV provides a dedicated place to assess and answer that question, which is incredibly important for seeing long-term wellbeing for a patient.”

Every 12 months after the initial or IPPE visit, a beneficiary may receive a subsequent AWV (G0439) to update and revise the risk assessment and continue to provide education and resources to the individual. 

What are the financial and quality impacts of AWVs?

AWVs can help primary care providers and their ACOs accomplish several major population health management goals that can lead to lower costs, better quality, and a higher likelihood of achieving shared savings.

In order to encourage participation, AWVs cost nothing for Medicare beneficiaries.  Unless a provider conducts a billable evaluation and management (E/M) service concurrently with the AWV, there is no copay, coinsurance, or deductible for the wellness visit itself.  

Since Medicare also wants to encourage primary care providers to complete these important services, reimbursement rates for initial and subsequent AWVs often equate to 50 percent more than a typical E/M visit.

“Paying for preventive care is what we would consider ‘good’ fee-for-service,” said Mostashari.  “Medicare is really pushing to make the most of what they can do within the fee-for-service structure to promote prevention, make it more attractive for patients to get this done, and give providers some financial support for investing time in these longer visits.”

There are also significant downstream benefits from making AWVs a routine component of patient care. 

In a 2019 study published in the American Journal of Managed Care (AJMC) and led by Aledade, researchers found that patients in Aledade ACOs who received AWVs saw an average decrease in healthcare spending of $450 per year, driven largely by fewer acute care and hospital outpatient visits.

Patients with average or low health risks saw a 5.7 percent reduction in annual costs after their first AWV, or an average of $38 per member per month (PMPM).

Individuals in higher risk categories saw even greater benefits.  Patients in the highest hierarchical condition category (HCC) risk quartile saw a 6.3 percent decrease in annual spending after their first AWV, or an average of $81 PMPM.

The AJMC study found that AWVs for all patients were associated with significantly better performance on key quality measures, including fall risk screening, depression screening and follow-up, A1C control, screenings for breast and colorectal cancer, and pneumococcal vaccination.

“When you compare patients who got an AWV and patients who didn’t, you see a big decrease in costs,” said Mostashari.  “For Medicare, the average savings is almost three times the investment they’re making to reimburse providers for these visits.”  

“That’s an excellent deal for the health system and for the patients it serves, particularly because the savings are correlated with fewer hospitalizations and more comprehensive screenings for potentially serious conditions.”

Why should primary care providers make AWVs a priority?

Despite their potential to support better health for patients and strong financial opportunities for providers, AWVs are significantly underutilized.  Only a quarter of Medicare beneficiaries received an AWV in 2015, according to the AARP

This is a missed opportunity for primary care providers, Mostashari stressed.  

“We want providers to view the AWV as a chance to complete a whole lot of important quality and wellness tasks at the same time,” he said.  “There’s something like 10 quality measures that you can address during an AWV. That’s a very efficient use of your time and the patient’s time, and we strongly believe that AWVs should be a much more widely used service.” 

Providers can make time for more AWVs in their schedules by identifying and focusing on the highest priority patients first, Mostashari continued.

“We think AWVs for higher risk patients are so important that the very first app we built at Aledade was a patient priority list,” he said.  

“We pull in their clinical history and risk factors, their pre-adjudicated 837 insurance claims, and the practice’s scheduling information – plus any available health information exchange data about recent hospital experiences – and create a ranked list of patients who really should be getting an AWV to stay on top of their issues.” 

Access to this information is critical for ensuring that both providers and patients see the value in completing AWVs annually, he concluded.

“AWVs are one of our core initiatives for a very good reason,” Mostashari said.  “We want to convince and persuade and motivate more of our practices that these are truly lifesaving and important.”

“Don't just treat it as a ‘check the box’ exercise. Really embrace the true meaning behind these wellness visits, and you will definitely see the impacts of making them a priority for your patients.”