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How to properly document wellness visits and physicals


Answers to billing and coding questions submitted by readers

Q: Our physicians perform a lot of annual wellness visits (AWVs) and preventive visits for Medicare patients. Can we use the same template for each of these visits?

A: Each template needs to be different. If the documentation for your initial or subsequent AWVs (G0438, G0439) resembles that of a preventive physical exam, you have a compliance problem. The claim won’t stand up to a Medicare audit. 

The encounter and documentation rules for AWVs, which are covered by Medicare, are vastly different from those of preventive visits (Current Procedural Terminology codes 99381 through 99387), which are not covered by Medicare.

The preventive physical documentation will not meet the requirements for an AWV because measuring the body mass index (BMI) and the patient’s depression are about the only elements they have in common. Also, keep in mind that the AWV requires a Health Risk Assessment that should first be filled out by the patient and reviewed by the physician with the patient. It should include demographic data, self-assessment of health status, psychosocial and behavioral health risks and activities of daily living.

Other components of an AWV are:

History: The patient’s past medical, surgical and family history, including medications and supplements, and current providers.

Assessment: The patient’s height, BMI (initial AWV only), weight, blood pressure and other measures deemed appropriate based on the patient’s family and medical history.

Cognitive function: Assessment and detection of any cognitive function impairment through observation and/or screening.

Screening schedule: A schedule of recommended, age-appropriate screenings for the patient to receive in the next five to 10 years based on recommendations from the U.S. Preventive Services Task Force and the patient’s health status and screening history.

Risk factors: A list of the patient’s current risk factors for conditions, including mental health, along with treatment options, risks and benefits.

Personalized health advice: Referrals to programs as needed (i.e. tobacco cessation, fall prevention, nutrition, weight loss, etc.)

Keep in mind that an initial or subsequent AWV is not a head-to-toe physical exam, contrary to what many patients believe. This needs to be clearly explained to the patient beginning with the appointment phone call.

An AWV (G0438/G0439), preventive physical (99381-99387) and an evaluation and management (E/M) service (99201-99215) can all be billed on the same date. However, your documentation must support each of these services. For the initial or subsequent AWV, all elements must be furnished and documented to bill to Medicare.

Make sure appointments are clearly marked for the AWV, so the patient fills out the appropriate paperwork and the physician uses the correct documentation template. This will require some additional training for your front-office staff, but it will pay off. Patients continue to be confused about the differences in the visits, so this will help patient relationships in addition to ensuring correct claim submissions.


The answer to the reader’s question was provided by Renee Dowling, a billing and coding consultant with VEI Consulting Services in Indianapolis, Indiana. Send your billing and coding questions to medec@advanstar.com.

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