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Annual Wellness Visit (AWV) documentation and coding

 

A Medicare Annual Wellness Visit (AWV) is not a typical physical exam. Rather, it’s an opportunity to promote quality, proactive, cost-effective care. AWVs help you engage with your patients and increase revenue.

 

A physician, PA, NP, certified clinical nurse specialist or a medical professional under the direct supervision of a physician (including health educators, registered dietitians and other licensed practitioners) can perform AWVs.

 

AWV documentation

 

Document all diagnoses and conditions to accurately reflect severity of illness and risk of high-cost care.

 

AWV coding

 

An ICD-10 Z code is the first diagnosis code to list for wellness exams to ensure that member financial responsibility is $0.

 

  • Z00.00 — encounter for general adult medical examination without abnormal findings
  • Z00.01 — encounter for general adult medical examination with abnormal findings

 

The two CPT® codes used to report AWV services are:*

 

  • G0438 — initial visit**
  • G0439 — subsequent visit (no lifetime limits)

 

Additional services (lab, X-rays, etc.) ordered during an AWV may be applied toward the patient’s

deductible and/or be subject to coinsurance. Before performing additional services, discuss them

with the patient to verify that the patient understands their financial responsibilities.

 

More information

 

For additional information and education, contact us at RiskAdjustment@aetna.com.

 

*CPT® is a registered trademark of the American Medical Association.

**Code G0438 is for the first AWV only. The submission of G0438 for a beneficiary for which a claim code of G0438 has already been paid will result in a denial.

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