Page 271 - Medicare Benefit Policy Manual

280.5 – Annual Wellness Visit (AWV) Providing Personalized
Prevention Plan Services (PPPS)
(Rev. 170, Issued: 05-10-13, Effective: 01-01-12, Medicare Coverage of the Annual
Wellness Visit (AWV); 01-01-13- Medicare Coverage of Hepatitis B Vaccine,
Implementation: 06-10-13)

A. General

Pursuant to section 4103 of the Affordable Care Act of 2010 (the ACA), the Centers for
Medicare & Medicaid Services (CMS) amended section 42 CFR 411.15(a)(1) and 42
CFR 411.15(k)(15) (list of examples of routine physical examinations excluded from
coverage), effective for services furnished on or after January 1, 2011. This expanded
coverage, as established at 42 CFR 410.15, is subject to certain eligibility and other
limitations that allow payment for an annual wellness visit (AWV) providing
personalized prevention plan services (PPPS), when performed by a health professional
(as defined in this section), for an individual who is no longer within 12 months after the
effective date of his/her first Medicare Part B coverage period, and 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.

The AWV will include the establishment of, or update to, the individual’s medical/family
history, measurement of his/her height, weight, body-mass index (BMI) or waist
circumference, and blood pressure (BP), with the goal of health promotion and disease
detection and encouraging patients to obtain the screening and preventive services that
may already be covered and paid for under Medicare Part B. Definitions relative to the
AWV are included below.

Coverage is available for an AWV that meets the following requirements:

1. It is performed by a health professional; and,

2. It is furnished to an eligible beneficiary who is no longer within 12 months
after the effective date of his/her first Medicare Part B coverage period, and
he/she has not received either an IPPE or an AWV providing PPPS within the past
12 months.

Sections 4103 and 4104 of the ACA also provide for a waiver of the Medicare
coinsurance and Part B deductible requirements for an AWV effective for services
furnished on or after January 1, 2011.

B. Definitions Relative to the AWV:

Detection of any cognitive impairment: The assessment of an individual’s cognitive
function by direct observation, with due consideration of information obtained by way of
patient reports, concerns raised by family members, friends, caretakers, or others.