Differentiating Between IPPE (G0402), AWV (G0438/G0439), and Annual Physical (99381-99397)

Differentiating Between IPPE (G0402), AWV (G0438/G0439), and Annual Physical (99381-99397)

Medicare offers various preventive services to help beneficiaries maintain their health. These services include the Initial Preventive Physical Examination (IPPE), Annual Wellness Visit (AWV), and the routine annual physical exam. Understanding the differences between these can help healthcare providers ensure accurate billing and inform patients about their coverage options. Let’s go over the components and billing codes for each type of Medicare preventive service.

Initial Preventive Physical Examination (IPPE) – G0402

The IPPE, often referred to as the “Welcome to Medicare” visit, is a one-time service offered to new Medicare Part B enrollees. It must be performed within the first 12 months of the patient’s Part B benefits eligibility date. The IPPE focuses on a comprehensive review of the patient’s medical and social history and includes education about preventive services.

Key Components of IPPE:

• Review of medical and social health history
• Assessment of potential depression risk factors
• Review of functional ability and safety
• Physical exam including height, weight, BMI, blood pressure, and visual acuity screen
• End-of-life planning
• Review of current opioid prescriptions and screening for substance use disorders
• Education, counseling, and referral for other preventive services

IPPE Billing Code:

G0402: “Initial preventive physical examination; face-to-face visit, services limited to new beneficiaries during the first 12 months of Medicare enrollment” (CMS).

Annual Wellness Visit (AWV) – G0438/G0439

The AWV is available to patients who have been enrolled in Medicare Part B for more than 12 months. Unlike the IPPE, the AWV is covered annually and focuses on developing or updating a personalized prevention plan based on a health risk assessment (HRA).

First AWV (G0438) Checklist from the CMS:

1. Perform an HRA:
   o Patient self-reported information, demographic data, health status self-assessment, psychosocial and behavioral risks, and activities of daily living (ADLs) and instrumental ADLs (IADLs).
2. Establish the patient’s medical and family history:
   o Medical events of the patient’s family, past medical and surgical history, and current medications, supplements, and other substances.
3. Establish a current providers and suppliers list:
   o Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.
4. Measure:
   o Height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure.
5. Detect any cognitive impairments the patient may have:
   o Assess cognitive function by direct observation or reported observations from others.
6. Review the patient’s potential depression risk factors:
   o Use standardized screening tools for depression.
7. Review the patient’s functional ability and level of safety:
   o Evaluate the ability to perform ADLs, fall risk, hearing impairment, and home and community safety.
8. Establish an appropriate patient-written screening schedule:
   o Based on the checklist for the next 5–10 years, and patient’s health status and screening history.
9. Establish the patient’s list of risk factors and conditions:
   o Include mental health conditions, treatment options, and recommendations for interventions.
10. Provide personalized patient health advice and appropriate referrals:
    o Referrals to educational and counseling services or programs to reduce health risks and promote wellness.
11. Provide advance care planning (ACP) services at the patient’s discretion:
    o Discussion about preparing an advance directive and future care decisions.
12. Review current opioid prescriptions:
    o Evaluate potential OUD risk factors, pain severity, and current treatment plan.
13. Screen for potential SUDs:
    o Review the patient’s potential SUD risk factors and refer them for treatment if appropriate.
14. Social Determinants of Health (SDOH) Risk Assessment:
    o Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV.

Key Components of Subsequent AWV (G0439):

• Review and update the HRA
• Update the patient’s medical and family history
• Update current providers and suppliers list
• Measure weight (or waist circumference) and blood pressure
• Detect any cognitive impairments
• Update the patient’s written screening schedule
• Update the patient’s list of risk factors and conditions
• Provide and update personalized health advice and appropriate referrals

AWV Billing Codes:

• G0438: “Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit” (CMS).
• G0439: “Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit” (CMS).

Annual Physical Exam (99381-99397)

Annual physical exams are comprehensive preventive exams that Medicare does not cover. These exams include a thorough physical examination and a detailed review of the patient’s medical history but do not follow the specific requirements of the IPPE or AWV.

Annual Physical Billing Codes:

99381-99397: Preventive medicine services; comprehensive, preventive evaluation and management of a patient (age and new/established patient status determine the exact code).

Quick Facts: Comparing IPPE, AWV, & Annual Physical

To recap, here’s a summary of these services and billing codes:

• IPPE (G0402): One-time, within the first 12 months of Part B enrollment, comprehensive review and preventive education.
• AWV (G0438/G0439): Annual, focuses on developing/updating a personalized prevention plan based on a health risk assessment.
• Annual Physical (99381-99397): Comprehensive preventive exam, not covered by Medicare, includes detailed physical examination and medical history review.

Visit the Medicare Wellness Visits page on the CMS website for more information about these services and billing codes.

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