Documentation of a Wellness Visit

What Data Should be Obtained and Recorded at a Wellness Visit?

Coding for an Annual Wellness Visit

The following is from the Medicare Claims Processing Manual Chapter 18: Preventative Services. It delineates what your provider must record in your medical record to bill Medicare without risk of fraud.

• [G0402 Initial Preventive Physical Examination (IPPE) or Welcome to Medicare Exam (Must be done within the first six months of the first coverage period under Medicare Part B)]

• [G0438 Annual Wellness Exam First Exam (If IPPE opportunity missed)]

• [G0438 Annual Wellness Exam established (11 months after last Wellness Exam]

Deductible and Coinsurance are waived for all three, meaning there is a $0 cost to the patient. The clinic is paid at the Evaluation & Management Level 4 amount with a diagnosis code of V70.0. Through the American Medical Association's CPT (Current Procedural Terminology) 9th edition, Medicare suggests at least 40 minutes of face-to-face time between patient and doctor.

Many of the other preventative services Medicare supports and listed at the bottom of this page are separately billed, and some have deductible and coinsurance waived, and others do not. They all have the frequency limitations and must be charged correctly and associated with the mandated diagnosis codes.

The medical record must record the following for a Medicare Annual Wellness Visit:

• Establishment or updating of a patient's medical and family history;

• A listing of the patient's current medical providers, suppliers, and all prescribed medications;

• Recording of measurements of height, weight, body mass index, blood pressure, visual acuity screen, and any other indicated routine measurements;

  • Note: there is no physical examination required. No looking in ears or eyes. No listening to lungs, heart, arteries. No palpation of the abdomen. No rectal or prostate or GYN exam. No skin exam. GYN and Prostate preventative exams should be done on a separate day and billed separately for optimal reimbursement.

• Detection of any cognitive impairment by using any appropriate screening instrument recognized by the national professional medical organizations.

• Detect risk factors for depression and other mood disorders using any appropriate screening instrument recognized by the national professional medical organizations.

• Review functional ability and level of safety (Quality of Life)using appropriate standardized questionnaires recognized by national professional medical organizations for

  • Hearing impairment,

  • Activities of daily living;

  • Falls risk;

  • Home safety.

• End of life planning in either verbal or written information about advance directives.

• Establishment or updating of a screening schedule for the next 5 to 10 years, including screenings appropriate for the general population and any additional screenings that may be appropriate because of the patient's risk factors.

• Furnishing of personalized health advice and appropriate referrals to health education or preventive services.

• Provide the patient with a written plan such as a checklist for other preventative tests recommended. (If the clinic provides the following on another day after the annual wellness visit, they can be separately billed. Medicare will waive deductible and co-pay requirements for the patient on many of the services. All have frequency limitations and other requirements of medically indicated. Bill using Medicare Claims Processing Manual Chapter 18 for codes and modifiers and diagnosis.)

Specific Preventative Screening Tests, Instruction, Counselling covered by the Affordable Care Act and Medicare:

• EKG: G0403 (New Medicare); G0404 (Annual Wellness New); G0405 (Annual Wellness Established) Coinsurance and Deductible Not Waived. V70.0 on day of Wellness Exam.

• Bone Mass Measurements: 77080 DEXA scan. Waived

• Cardiovascular Disease Screening Blood Tests: 80061 Lipid panel. Waived

• Colorectal Cancer Screening: 82270 3-occult blood in stool waived; G0121 Colonoscopy. Waived

• Counseling to Prevent Tobacco Use for Asymptomatic Patients: G0432-G0437. Waived (3-10 min sessions)

• Diabetes Screening Tests: 82947 Fasting Glucose. Waived

• Diabetes Self-Management Training (DSMT): G0108 30 minutes; G0109 Group 60 minutes. Neither is Waived.

• Glaucoma Screening: G0117. Not Waived

• Human Immunodeficiency Virus (HIV) Screening: G0432-G0435. Waived

• Influenza, Pneumococcal and Hepatitis B Vaccinations and their Administration: 90669-90673 waived plus G0009 Administration. Waived.

• Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD), also referred to as a CVD risk reduction visit: G0446 annual 15 min session. Waived

• Intensive Behavioral Therapy (IBT) for Obesity: G0447 Dx V85.30-V85.39 and V85.41-V85.45. Twenty-two sessions for 12 months. Waived

• Medical Nutrition Therapy (MNT): 97803 initial; 97803 Re-assessment; 97804 Group. All Waived

• Prostate Cancer Screening: G0102 Digital exam. Not Waived; G0103 PSA. Waived.

• Screening and Behavioral Counseling Interventions in Primary Care to reduce Alcohol Misuse: (Defined seven or higher standard drinks per week for women and 14 or higher standard drinks per week for men.) G0442 screening session 15 min and G0443 brief counseling sessions 15 min 4 per 12 months.

• Screening for Depression in Adults: G0444 (15 minutes annually)

• Screening Mammography: G0202 Digital mammogram. Waived.

• Screening Pap Tests and Pelvic Examination: G0101 Pelvic, PAP, Breast Exam: Waived if 35 months since last done or 11 months if tests positive or 11 months it had more than five-lifetime sexual partners.

• Sexually Transmitted Infections (STIs) Screening: Chlamydia 86631; Gonorrhea 87590; Syphilis 86592; Hepatitis B 87340.

• Behavioral Counseling (HIBC) to Prevent STIs: G0445 30 min semi-annually.

• Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)

  • NOTE: Eligible beneficiaries must receive a referral for an ultrasound screening for AAA from their physician, physician assistant, nurse practitioner, or clinical nurse specialist. Must have a history of tobacco abuse.

Patients may take a copy of this page to their Annual Wellness Visit

Below there is a PDF document containing this page.

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