According to the Affordable Care Act of 2010 (ACA), the Centers for Medicare & Medicaid Services (CMS) expanded coverage for AWVs. Any individual who is no longer within 12 months of the effective date of their first Medicare Part B coverage period has not received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months. Medicare coinsurance and Part B deductibles do not apply.

G0438- Annual Wellness Visit includes a personalized prevention plan of service (PPS) first visit.
G0439- Annual Wellness Visit, includes a personalized prevention plan of service (PPS) subsequent visit.

The timing of these services is not negotiable, therefore services outside the payable periods so require an Advance Beneficiary Notice of Noncoverage (ABN)

There is no deductible nor coinsurance for an AWV. The patient would have no cost responsibility unless receiving another service simultaneously. You might have to explain this to the patient.

Medicare will verify that at least 11 full calendar months have passed since the last AWV.

Medicare allows the provision of both services. You can find more information on CMS IOM, Publication 100-04, Chapter 12.

No, the First AWV visit is billed by another code.

A provider can bill for both services when the E/M service is significant and separately identifiable from the AWV. Providers should report a modifier 25 when appropriate. A modifier 25 is used to report an E/M procedure code when another service was provided to the patient by the same physician or other qualified healthcare providers. If the E/M component is part of the AWV, this should not be included when defining the appropriate E/M Code.

Yes, Medicare would not deny this service.

Yes, the procedure should be billed to the primary insurance and Medicare. The claims to Medicare shall be sent as secondary payment. Medicare will make the payment if the primary denies it because they do not recognize the procedure code.