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Making the Most out of Medicare Preventive Services

Authors: Ronald Viggiani, MD; Emma Hitt, PhDFaculty and Disclosures

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Posted: 06/16/2011

"An ounce of prevention is worth a pound of cure." That axiom is perhaps more true today than it was when Benjamin Franklin espoused the idea more than 200 years ago, especially for Medicare beneficiaries.

A number of preventive services have been covered by Medicare for some time. In 2011, however, a new opportunity has become available—the Annual Wellness Visit (AWV)—which expands upon the already available services. In addition, the copayment/coinsurance and deductibles are now waived for many of these preventive measures.

Annual Wellness Visit

The Affordable Care Act allows for coverage of the AWV, which is a yearly office visit that focuses on preventive health. During the AWV, health care providers will review a patient’s history and risk factors for diseases, ensure that the patient’s medication list is up to date, and provide personalized health advice and counseling. The first AWV also allows the provider to establish a written preventive screening schedule. View a complete listing of the AWV components.[1] In addition to understanding the components of the AWV, it is important for providers to understand specific coverage information for this benefit so that they can schedule and bill for this service properly (Table).[2]

AWVs can be performed by physicians, physician assistants, nurse practitioners, clinical nurse specialists, and other licensed members of the health care team, allowing flexibility with how this service is provided to beneficiaries.[1] Beneficiaries can receive an AWV at any point after their first 12 months on Medicare: there is no time limit by which Medicare will no longer cover an AWV.

The national payment rate for the initial AWV is $161.05 in 2011; starting in 2012 the rate for a follow-up AWV will be $107.37 (if 2011 pay rates are carried over).[3] Medical coinsurance or copayments and Part B deductibles do not apply to the AWV.[2]

For more information on the AWV, see Quick Reference Information: The ABCs of Providing the Annual Wellness Visit.[4]

Initial Preventive Physical Examination ("Welcome to Medicare" Visit)

Most clinicians are familiar with the Initial Preventive Physical Examination (IPPE), commonly known as the "Welcome to Medicare" visit. This exam has been available since 2005 and is provided as a one-time service to new Medicare beneficiaries (Table).[2,5]

The IPPE must be performed within the first 12 months after the beneficiary’s effective date of Part B coverage.[2] It contains a number of components that focus on prevention, including a complete medical/social/family history, a focused physical examination (eg, body mass index, blood pressure, visual acuity), an assessment of functional ability, and counseling.[5]

The current payment rate for the IPPE is $147.80[6] and like the AWV, medical coinsurance or copayments and Part B deductibles do not apply.[2]

For more information on the IPPE, see Quick Reference Information: The ABCs of Providing the Initial Preventive Physical Examination.[7]

Table. Details on the Annual Wellness and the "Welcome to Medicare" Visits

Service Who is covered Frequency
Annual Wellness Visit* (AWV) All Medicare beneficiaries who have had Part B coverage for at least 12 months. The initial visit cannot take place within 12 months of the beneficiary’s IPPE. Annually

(Note there are separate HCPCS/CPT codes for the first AWV visit [G0438] and subsequent AWV visits [G0439])
Initial Preventive Physical Examination (IPPE, also known as the "Welcome to Medicare" visit) All Medicare beneficiaries, within the first 12 months after their Part B coverage effective date. Only one time per beneficiary

(and must be furnished no later than 12 months after the effective date of the first Medicare Part B coverage)
HCPCS = Healthcare Common Procedure Coding System; CPT = Current Procedural Terminology
*This is a new benefit that began on 01/01/11.
From Centers for Medicare & Medicaid Services. Quick Reference Information: Preventive Services. Accessed May 21, 2011.[2]

OTHER PREVENTIVE SERVICES

Medicare continues to provide numerous other preventive services targeting cardiovascular disease, diabetes, and cancer, as well as vaccinations and counseling services.[2] One-on-one medical nutrition therapy counseling provided by a registered dietitian is also covered (three hours during the first year of coverage and two hours during subsequent years) for beneficiaries diagnosed with diabetes or kidney disease, or who are recovering from a kidney transplant.[2] View a quick reference chart outlining all covered preventive services.[2]

Importantly, the Affordable Care Act now allows for many of these preventive services to be provided without the need for beneficiary copayment/coinsurance or deductible.[2]

Given these expanded opportunities for preventive services, Medicare providers and beneficiaries can now, more than ever, reap the benefits of health promotion and disease prevention.

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