Understanding Medicare Preventive Visits: Welcome to Medicare IPPE vs. Initial Annual Wellness Visit AWV

Understanding Medicare Preventive Visits: Welcome to Medicare IPPE vs. Initial Annual Wellness Visit AWV

Medicare preventive visits often create confusion among healthcare providers and coding staff, particularly regarding when to use G0402 (Welcome to Medicare Visit, IPPE) versus G0438 (Initial Annual Wellness Visit, AWV). This guide will clarify the key differences, similarities, and proper coding scenarios for each visit type.

Important Note: ALL components of these visits must be documented in the medical record to bill for these services. Missing even one required element makes the claim unbillable.

When to Code Each Medicare Preventative Visit

G0402 (Welcome to Medicare IPPE Visit)

• Must be completed within the first 12 months of Medicare Part B enrollment.
• Can only be billed once in a beneficiary’s lifetime.
• Cannot be billed if the patient has already received a G0438.
• If missed within the first 12 months, the opportunity expires.

G0438 (Initial Annual Wellness Visit)

• Can only be performed after the first 12 months of Medicare Part B enrollment.
• Can be billed even if the patient never had a G0402.
• Can only be billed once in a lifetime.
• Subsequent annual wellness visits will be coded as G0439.

Shared Elements Between Medicare IPPE and Annual Wellness Visits

1. Medical History Review

• Both require a review of medical, family, and social history.
• Both include medication review.
• Both assess for substance use and opioid prescriptions

2. Depression Screening

• Both require assessment of depression risk factors.
• Both allow the use of standardized screening tools.

3. Functional Ability Assessment

• Both evaluate activities of daily living (ADLs) and safety.
• Both include a fall risk assessment.
• Both assess home and community safety.

4. Vital Signs

• Both require basic measurements (height, weight, BMI, blood pressure).

5. End-of-Life Planning

• Both include a discussion of advance directives.
• Both are optional based on patient agreement.

6. Substance Use Screening

• Both include opioid prescription review.
• Both require a substance use disorder (SUD) screening when appropriate.

Key Differences Between Medicare IPPE and Annual Wellness Visits

Unique to G0402 (Welcome to Medicare)

1. Visual acuity screening requirement
2. One-time screening ECG when appropriate
3. More focused on establishing baseline health status
4. Must occur within the first 12 months of Part B enrollment

Unique to G0438 (Initial AWV)

1. Requires Health Risk Assessment (HRA)
2. Includes cognitive impairment assessment
3. Creates 5- to 10-year screening schedule
4. Optional SDOH Risk Assessment (starting 2024)
5. More comprehensive provider/supplier list
6. More detailed personalized prevention plan

Common Coding Scenarios and Solutions

Scenario 1: New Medicare Patient

• If within the first 12 months of Part B: Code G0402.
• If beyond 12 months: Code G0438.

Scenario 2: G0402 Already Performed

• Must wait until after the first 12 months of Part B enrollment.
• Then code G0438 for first AWV.
• Subsequent years will be G0439.

Scenario 3: No Previous G0402

• If beyond 12 months of Part B enrollment.
• Can proceed directly to G0438.
• No need to perform G0402 first.

Scenario 4: Same-Day Services

• G0402 and G0438 cannot be billed on the same day.
• Neither can be billed with a problem-oriented visit unless a significant separate service was provided.
• Modifier -25 may be needed for separate evaluation and management service.

Best Practices for Reporting Medicare IPPE & AWV

1. Always verify the Medicare Part B effective date before scheduling.
2. Document clearly which visit type was performed.
3. Maintain a tracking system for Medicare preventive services.
4. Educate scheduling staff on timing requirements.
5. Create checklist templates specific to each visit type.

Final Insights on Medicare IPPE & Annual Wellness Visit Requirements

Understanding the distinct requirements and appropriate timing of G0402 and G0438 is crucial for proper coding and reimbursement. While these visits share many elements, their unique components and timing requirements make them distinct services. Maintaining clear documentation and verification processes will help ensure proper coding and prevent claim denials.

Refer to our previous article for additional help differentiating between IPPE, AWV, and Annual Physical. If your coding team or clinicians need documentation support or education regarding these services, reach out to our team to see how we can help you today.

Important Note: Medicare requirements and guidelines may change. Always verify current requirements through official CMS documentation.