welcome to medicare visit provider

You and your patient have a lot of ground to cover. Here’s one way to get it all done .

RANDALL O. CARD, MD, FAAFP

Fam Pract Manag. 2005;12(4):27-31

The new Welcome to Medicare exam revolves around preventive health care, something family physicians have always incorporated into their practice. But as you work out your routine for performing these visits, you might need to reframe your thinking about what constitutes a physical exam.

The new Medicare exam includes seven elements, and they add up to a patient encounter that is as much of a conversation as it is a physical exam. Making sure you cover all of the required elements in the allotted time takes a well-planned routine. If you haven’t already developed such a routine, this article suggests some time-saving strategies. The encounter form in this article will help you to ensure all elements of the initial preventive physical exam are completed. The form also should help you meet evaluation and management (E/M) documentation requirements.

The essential elements

As part of the Medicare Modernization Act (MMA), Medicare beneficiaries whose Part B coverage began after Jan. 1, 2005, and who are within six months of the effective date of their coverage are eligible for one initial preventive physical exam. The exam focuses on identifying modifiable risk factors for medical conditions that frequently affect the elderly, as well as education, counseling and referral for Medicare-covered preventive services.

Here are the seven required elements:

1. Review of comprehensive medical and social history. The purpose of this element is to identify modifiable risk factors for disease.

The medical history component should include illnesses, hospitalizations, surgeries, injuries, allergies, medications, supplements and vitamins. Social issues to address include alcohol, tobacco and illicit drug use; diet; and physical activities. The family history is performed to identify hereditary diseases or diseases that otherwise place the patient at increased risk for disease.

2. Review of risk factors for depression. This next element involves identifying depression and other mood disorders. The Centers for Medicare & Medicaid Services (CMS) does not recommend a specific depression screening tool. Instead, CMS states that you “may select from various available standardized screening tests designed for this purpose.” 1

Many standardized depression screening tools are too cumbersome to use in a short office visit. One quick technique recommended by the U.S. Preventive Services Task Force (USPSTF) involves asking two questions: “Over the past two weeks, have you felt down, depressed or hopeless?” and “Over the past two weeks, have you felt little interest or pleasure in doing things?” An affirmative answer to either may be as effective as more detailed instruments in identifying a patient who needs further evaluation for depression. 2

BILLING FOR A WELCOME TO MEDICARE VISIT

Along with settling on a new routine for the Welcome to Medicare exam, you’ll also want to make sure you understand its billing requirements.

For a complete overview, see “New Year, New Medicare Benefits,” FPM, February 2005, page 15 .

3. Review of functional ability and level of safety. You have a lot of leeway with this element, which requires you to evaluate your patient’s hearing, activities of daily living, functional ability and level of safety. As with the depression screening, CMS accepts any appropriate screening test that is recognized by national medical professional groups.

For determining fall risk, I recommend following the American Geriatrics Society’s (AGS) clinical guidelines. According to the AGS, there are two tests that should trigger further patient evaluation: if your patient previously has received treatment for a fall, or if your patient takes longer than 30 seconds for an “Up & Go” test. 3

The timed Up & Go test involves having the patient stand up from a chair, walk three meters, turn around, walk back to the chair and sit back down. If the patient takes longer then 30 seconds or seems unsteady, the test is considered positive for increased fall risk.

To identify functional challenges, the CDC advises screening your patients by inquiring about their instrumental activities of daily living (IADLs). This involves asking patients about troubles using a phone, using transportation, grocery shopping, preparing meals, doing housework, doing laundry, taking medications and managing money. Any limitation to their IADLs that you identify as being caused by a chronic condition warrants further evaluation.

While functional assessments have been researched extensively, less evidence exists for home safety screening. The CDC recommends that elderly patients improve home safety by removing tripping hazards in walkways, using non-slip mats in bathtubs and showers, placing grab bars next to the toilet and shower, placing handrails on both sides of a stairway and improving home lighting. It seems reasonable to question patients about these items during the initial preventive physical exam.

For the hearing evaluation, I plan to follow the USPSTF’s recommendation to simply question patients about their hearing function. There are, of course, more elaborate testing methods, but the USPSTF found insufficient evidence to recommend for or against them. 4

Your screening for depression risk, functional ability and level of safety should be accompanied by further evaluation, including a full diagnostic workup, for any patients with positive responses. The workup can be performed in conjunction with the initial preventive physical exam, or the patient can be further evaluated later. CMS will allow a level-one or level-two E/M code with a -25 modifier attached to be billed with the initial preventive physical exam. If you conclude that the depression or fall risk does not warrant immediate care but will require a level-three or higher E/M service, it might be prudent to perform the full workup at a later date.

4. A focused physical exam. This should be an extremely focused physical exam. Height, weight, blood pressure and visual acuity are the only required components. No specific vision tests are mandated, but using the Snellen chart is appropriate.

5. Performance and interpretation of an electrocardiogram. Some offices have the capacity to handle this, and others will need to send the patient to another facility. Either way, the ECG results need to be incorporated into your patient’s medical record to complete the initial preventive physical exam.

If the patient is sent to another facility for the ECG, the order must read “ECG as part of the Welcome to Medicare Physical, codes G0366–G0368.” Medicare has instructed that physicians must order the ECG in a manner that helps to prevent use of codes for ECGs not related to the initial preventive physical exam.

6. Brief education, counseling and referral to address any pertinent health issues identified during the first five elements of the exam. CMS expects the amount of time required for this step to vary depending on the problems that you discovered in the first five elements.

7. Brief education, counseling and referral, with maintenance of a written plan (such as a checklist), regarding separate preventive care services covered by Medicare Part B. There are now 11 preventive services authorized under Medicare Part B. Coverage for the two newest ones, cardiovascular disease screening and diabetes screening, became effective on Jan. 1, 2005. For the full list, see “Preventive services covered by Medicare Part B.”

It is important that you thoroughly understand Medicare’s policy on these services before counseling your patient. Some services are covered at 100 percent of the Medicare allowable charge, and some services are covered at 80 percent of the Medicare allowable charge. In addition, some of the services are covered only if medically indicated.

Kent J. Moore, AAFP’s manager for health care and delivery systems, has written two FPM articles that cover these Part B services. “Another Ounce of Prevention” ( November/December 2002, page 25 ) covers most of the benefits, and “New Year, New Medicare Benefits” ( February 2005, page 15 ) summarizes the two new ones.

PREVENTIVE SERVICES COVERED BY MEDICARE PART B

Pneumococcal, influenza and hepatitis B vaccines

Screening mammography

Screening Pap smear/pelvic exam

Prostate cancer screening

Colorectal cancer screening

Diabetes outpatient self-management training services

Bone mass measurements

Screening for glaucoma

Medical nutritional therapy for individuals with diabetes or renal disease

Cardiovascular screening blood tests

Diabetes screening tests

Put it in writing

A checklist or another method of documentation indicating that the seven elements of the initial preventive physical exam have been addressed must be maintained in the patient record. The encounter form has been designed to do that.

In addition, you are required to give your patient a written plan for obtaining the appropriate preventive services. I suggest that you make a copy of the form’s second page to give to the patient at the exam’s conclusion. If you want to get fancy, you could design a similar form with a duplicate page two, allowing you to keep the original and give the carbon copy to the patient.

MEDICARE INITIAL PREVENTIVE PHYSICAL EXAMINATION ENCOUNTER FORM

This form has been updated since its original publication date to reflect changes to Medicare's covered services. You can download the updated encounter form as a PDF here.

A timed exchange

Over time, you will become more adept at completing the initial preventive physical exam in a reasonable period. CMS considers the physician/non-physician provider time component of the initial preventive physical exam to be equivalent to a 30-minute 99203 (new patient, level-three E/M code).

To speed the process along, you could use preprinted patient education materials to counsel your patient. For some specific examples available on Familydoctor.org, AAFP’s patient education Web site, see “Preprinted handouts.” It would also be helpful to ask your patients to bring to the visit the “Guide to Medicare’s Preventive Services,” which each new beneficiary is receiving in their Welcome to Medicare package. It can be viewed or downloaded at https://www.medicare.gov/Pubs/pdf/10110.pdf .

PREPRINTED HANDOUTS

Familydoctor.org has patient education materials regarding many of the preventive health issues covered in an initial preventive physical exam.

Breast cancer screening

https://familydoctor.org/familydoctor/en/diseases-conditions/cancer/diagnosis-tests.html

Cardiovascular blood tests

https://familydoctor.org/029.xml

Colon cancer screening

https://familydoctor.org/familydoctor/en/diseases-conditions/colorectal-cancer/diagnosis-tests.html

Diabetes screening

https://familydoctor.org/familydoctor/en/diseases-conditions/diabetes/diagnosis-tests.html

https://familydoctor.org/familydoctor/en/diseases-conditions/glaucoma/diagnosis-tests.html

Osteoporosis

https://familydoctor.org/familydoctor/en/diseases-conditions/osteoporosis/diagnosis-tests.html

https://familydoctor.org/familydoctor/en/diseases-conditions/prostate-cancer/diagnosis-tests.html

Screening Pap/pelvic

As you perfect your Welcome to Medicare exam routine, you should also refine how your office handles this new Medicare benefit before patients are even in the exam room. Identify new Medicare-eligible patients. Schedule the patients in a timely manner. Perform some of the screening before the face-to-face encounter.

The initial preventive physical exam is an opportunity for you and your newly enrolled Medicare patients to start thinking about Medicare-covered preventive services. Effective, efficient use of the initial preventive physical exam requires physicians and non-physician providers to understand the specific components of the initial preventive physical exam. A systems approach to identifying, educating and counseling patients regarding Medicare-covered preventive services may improve patient health and help physicians deliver the initial preventive physical exam in a financially sound manner.

CMS Manual System. Pub. 100–04 Medicare claims processing. Dec. 22, 2004.

U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med . 2002;136:760-764.

Kenny RA, Rubenstein LZ, Martin FC, et al. Guideline for the prevention of falls in older persons. J Am Geriatr Soc . 2001;49:664-672.

U.S. Preventive Services Task Force. Screening for hearing impairment. In: Guide to clinical preventive services: a report of the U.S. Preventive Services Task Force. 2nd ed. Baltimore: Williams & Wilkins; 1996:393–405.

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Copyright © 2005 by the American Academy of Family Physicians.

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Medicare Wellness Visits Back to MLN Print November 2023 Updates

What’s Changed?

• Added information about monthly chronic pain management and treatment services
• Added information about checking for cognitive impairment during annual wellness visits
• Added information about Social Determinants of Health Risk Assessments as an optional element of annual wellness visits

Quick Start

The Annual Wellness Visits video helps you understand these exams, as well as their purpose and claim submission requirements.

Medicare Physical Exam Coverage

Initial Preventive Physical Exam (IPPE)

Review of medical and social health history and preventive services education.

✔ New Medicare patients within 12 months of starting Part B coverage

✔ Patients pay nothing (if provider accepts assignment)

Annual Wellness Visit (AWV)

Visit to develop or update a personalized prevention plan and perform a health risk assessment.

✔ Covered once every 12 months

Routine Physical Exam

Exam performed without relationship to treatment or diagnosis of a specific illness, symptom, complaint, or injury.

✘ Medicare doesn’t cover a routine physical

✘ Patients pay 100% out-of-pocket

Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health :

• Health Equity Technical Assistance Program
• Disparities Impact Statement

Communication Avoids Confusion

As a health care provider, you may recommend that patients get services more often than we cover or that we don’t cover. If this happens, help patients understand they may have to pay some or all costs. Communication is key to ensuring patients understand why you’re recommending certain services and whether we cover them.

Initial Preventive Physical Exam

The initial preventive physical exam (IPPE), also known as the “Welcome to Medicare” preventive visit, promotes good health through disease prevention and detection. We pay for 1 IPPE per lifetime if it’s provided within the first 12 months after the patient’s Part B coverage starts.

1. Review the patient’s medical and social history

At a minimum, collect this information:

• Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments)
• Current medications, supplements, and other substances the person may be using
• Family history (review the patient’s family and medical events, including hereditary conditions that place them at increased risk)
• Physical activities
• Social activities and engagement
• Alcohol, tobacco, and illegal drug use history

Learn information about Medicare’s substance use disorder (SUD) services coverage .

2. Review the patient’s potential depression risk factors

Depression risk factors include:

• Current or past experiences with depression
• Other mood disorders

Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. APA’s Depression Assessment Instruments has more information.

3. Review the patient’s functional ability and safety level

Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the patient’s:

• Ability to perform activities of daily living (ADLs)
• Hearing impairment
• Home and community safety, including driving when appropriate

Medicare offers cognitive assessment and care plan services for patients who show signs of impairment.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), blood pressure, balance, and gait
• Visual acuity screen
• Other factors deemed appropriate based on medical and social history and current clinical standards

5. End-of-life planning, upon patient agreement

End-of-life planning is verbal or written information you (their physician or practitioner) can offer the patient about:

• Their ability to prepare an advance directive in case an injury or illness prevents them from making their own health care decisions
• If you agree to follow their advance directive
• This includes psychiatric advance directives

6. Review current opioid prescriptions

For a patient with a current opioid prescription:

• Review any potential opioid use disorder (OUD) risk factors
• Evaluate their pain severity and current treatment plan
• Provide information about non-opiod treatment options
• Refer to a specialist, as appropriate

The HHS Pain Management Best Practices Inter-Agency Task Force Report has more information. Medicare now covers monthly chronic pain management and treatment services .

7. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them to treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

8. Educate, counsel, and refer based on previous components

Based on the results of the review and evaluation services from the previous components, provide the patient with appropriate education, counseling, and referrals.

9. Educate, counsel, and refer for other preventive services

Include a brief written plan, like a checklist, for the patient to get:

• A once-in-a-lifetime screening electrocardiogram (ECG), as appropriate
• Appropriate screenings and other covered preventive services

Use these HCPCS codes to file IPPE and ECG screening claims:

Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment

Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv

* Section 60.2 of the Medicare Claims Processing Manual, Chapter 9 has more information on how to bill HCPCS code G0468.

Report a diagnosis code when submitting IPPE claims. We don’t require you to use a specific IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an IPPE when performed by a:

• Physician (doctor of medicine or osteopathy)
• Qualified non-physician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist)

When you provide an IPPE and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

CPT only copyright 2022 American Medical Association. All rights reserved.

IPPE Resources

• 42 CFR 410.16
• Section 30.6.1.1 of the Medicare Claims Processing Manual, Chapter 12
• Section 80 of the Medicare Claims Processing Manual, Chapter 18
• U.S. Preventive Services Task Force Recommendations

No. The IPPE isn’t a routine physical that some patients may get periodically from their physician or other qualified non-physician practitioner (NPP). The IPPE is an introduction to Medicare and covered benefits, and it focuses on health promotion, disease prevention, and detection to help patients stay well. We encourage providers to inform patients about the AWV during their IPPE. The Social Security Act explicitly prohibits Medicare coverage of routine physical exams.

No. The IPPE and AWV don’t include clinical lab tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.

No. We waive the coinsurance, copayment, and Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening electrocardiogram (ECG) (HCPCS codes G0403, G0404, or G0405).

A patient who hasn’t had an IPPE and whose Part B enrollment began in 2023 can get an IPPE in 2024 if it’s within 12 months of the patient’s Part B enrollment effective date.

We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, find your MAC’s website .

Annual Wellness Visit Health Risk Assessment

The annual wellness visit (AWV) includes a health risk assessment (HRA). View the HRA minimum elements summary below. A Framework for Patient-Centered Health Risk Assessments has more information, including a sample HRA.

Perform an HRA

• You or the patient can update the HRA before or during the AWV
• Consider the best way to communicate with underserved populations, people who speak different languages, people with varying health literacy, and people with disabilities
• Demographic data
• Health status self-assessment
• Psychosocial risks, including, but not limited to, depression, life satisfaction, stress, anger, loneliness or social isolation, pain, suicidality, and fatigue
• Behavioral risks, including, but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (for example, seat belt use), and home safety
• Activities of daily living (ADLs), including dressing, feeding, toileting, and grooming; physical ambulation, including balance or fall risks and bathing; and instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, transportation, shopping, managing medications, and handling finances

1. Establish the patient’s medical and family history

At a minimum, document:

• Medical events of the patient’s parents, siblings, and children, including hereditary conditions that place them at increased risk
• Use of, or exposure to, medications, supplements, and other substances the person may be using

2. Establish a current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure
• Other routine measurements deemed appropriate based on medical and family history

4. Detect any cognitive impairments the patient may have

Check for cognitive impairment as part of the first AWV.

Assess cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others. Consider using brief cognitive tests, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Alzheimer’s and Related Dementia Resources for Professionals has more information.

5. Review the patient’s potential depression risk factors

6. Review the patient’s functional ability and level of safety

• Ability to perform ADLs

7. Establish an appropriate patient written screening schedule

Base the written screening schedule on the:

• Checklist for the next 5–10 years
• United States Preventive Services Task Force and Advisory Committee on Immunization Practices (ACIP) recommendations
• Patient’s HRA, health status and screening history, and age-appropriate preventive services we cover

8. Establish the patient’s list of risk factors and conditions

• A recommendation for primary, secondary, or tertiary interventions or report whether they’re underway
• Mental health conditions, including depression, substance use disorders , suicidality, and cognitive impairments
• IPPE risk factors or identified conditions
• Treatment options and associated risks and benefits

9. Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs

Include referrals to educational and counseling services or programs aimed at:

• Fall prevention
• Physical activity
• Tobacco-use cessation
• Social engagement
• Weight loss

10. Provide advance care planning (ACP) services at the patient’s discretion

ACP is a discussion between you and the patient about:

• Preparing an advance directive in case an injury or illness prevents them from making their own health care decisions
• Future care decisions they might need or want to make
• How they can let others know about their care preferences
• Caregiver identification
• Advance directive elements, which may involve completing standard forms

Advance directive is a general term that refers to various documents, like a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. The Advance Care Planning fact sheet has more information.

We don’t limit how many times the patient can revisit the ACP during the year, but cost sharing applies outside the AWV.

11. Review current opioid prescriptions

• Review any potential OUD risk factors
• Provide information about non-opioid treatment options

12. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them for treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

13. Social Determinants of Health (SDOH) Risk Assessment

Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and ensure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate.

1. Review and update the HRA

2. Update the patient’s medical and family history

At a minimum, document updates to:

3. Update current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including those added because of the first AWV personalized prevention plan services (PPPS), and any behavioral health providers.

• Weight (or waist circumference, if appropriate) and blood pressure

5. Detect any cognitive impairments patients may have

Check for cognitive impairment as part of the subsequent AWV.

6. Update the patient’s written screening schedule

Base written screening schedule on the:

7. Update the patient’s list of risk factors and conditions

• Mental health conditions, including depression, substance use disorders , and cognitive impairments
• Risk factors or identified conditions

8. As necessary, provide and update patient PPPS, including personalized health advice and appropriate referrals to health education or preventive counseling services or programs

9. Provide advance care planning (ACP) services at the patient’s discretion

10. Review current opioid prescriptions

11. Screen for potential substance use disorders (SUDs)

12. Social Determinants of Health (SDOH) Risk Assessment

Preparing Eligible Patients for their AWV

Help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment:

• Medical records, including immunization records
• Detailed family health history
• Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
• Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists

Use these HCPCS codes to file AWV claims:

Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

Report a diagnosis code when submitting AWV claims. We don’t require you to use a specific AWV diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an AWV if performed by a:

• Medical professional (including health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of medical professionals directly supervised by a physician

When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV, and G0439 is for subsequent AWVs. Don’t bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. We deny these claims with messages indicating the patient reached the benefit maximum for the time period.

Medicare telehealth includes HCPCS codes G0438 and G0439.

ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a patient to discuss their health care wishes and medical treatment preferences if they become unable to communicate or make decisions about their care. At the patient’s discretion, you can provide the ACP during the AWV.

Use these CPT codes to file ACP claims as an optional AWV element:

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Report a diagnosis code when submitting an ACP claim as an optional AWV element. We don’t require you to use a specific ACP diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

We waive both the Part B ACP coinsurance and deductible when it’s:

• Provided on the same day as the covered AWV
• Provided by the same provider as the covered AWV
• Billed with modifier 33 (Preventive Service)
• Billed on the same claim as the AWV

We waive the ACP deductible and coinsurance once per year when billed with the AWV. If we deny the AWV billed with ACP for exceeding the once-per-year limit, we’ll apply the ACP deductible and coinsurance .

We apply the deductible and coinsurance when you deliver the ACP outside the covered AWV. There are no limits on the number of times you can report ACP for a certain patient in a certain period. When billing this service multiple times, document changes in the patient’s health status or wishes about their end-of-life care.

SDOH is important in assessing patient histories; in assessing patient risk; and in guiding medical decision making, prevention, diagnosis, care, and treatment. In the CY 2024 Medicare Physician Fee Schedule final rule , we added a new SDOH Risk Assessment as an optional, additional element of the AWV. At both yours and the patient’s discretion, you may conduct the SDOH Risk Assessment during the AWV.

Use this HCPCS code to file SDOH Risk Assessment claims as an optional AWV element:

Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes

Report a diagnosis code when submitting an SDOH Risk Assessment claim as an optional AWV element. We don’t require you to use a specific SDOH Risk Assessment diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

The implementation date for SDOH Risk Assessment claims is July 1, 2024. We waive both the Part B SDOH Risk Assessment coinsurance and deductible when it’s:

We waive the SDOH Risk Assessment deductible and coinsurance once per year when billed with the AWV.

If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when you deliver the SDOH Risk Assessment outside the covered AWV.

AWV Resources

• 42 CFR 410.15
• Section 140 of the Medicare Claims Processing Manual, Chapter 18

No. The AWV isn’t a routine physical some patients may get periodically from their physician or other qualified NPP. We don’t cover routine physical exams.

No. We waive the coinsurance, copayment, and Part B deductible for the AWV.

We cover an AWV for all patients who’ve had Medicare coverage for longer than 12 months after their first Part B eligibility date and who didn’t have an IPPE or AWV within those past 12 months. We cover only 1 IPPE per patient per lifetime and 1 additional AWV every 12 months after the date of the patient’s last AWV (or IPPE). Check eligibility to find when a patient is eligible for their next preventive service.

Generally, you may provide other medically necessary services on the same date as an AWV. The deductible and coinsurance or copayment applies for these other medically necessary and reasonable services.

You have different options for accessing AWV eligibility information depending on where you practice. Check eligibility to find when a patient is eligible for their next preventive service. Find your MAC’s website if you have specific patient eligibility questions.

Know the Differences

An IPPE is a review of a patient’s medical and social health history and includes education about other preventive services .

• We cover 1 IPPE per lifetime for patients within the first 12 months after their Part B benefits eligibility date
• We pay IPPE costs if the provider accepts assignment

An AWV is a review of a patient’s personalized prevention plan of services and includes a health risk assessment.

• We cover an annual AWV for patients who aren’t within the first 12 months after their Part B benefits eligibility date
• We cover an annual AWV 12 months after the last AWV’s (or IPPE’s) date of service
• We pay AWV costs if the provider accepts assignment

A routine physical is an exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.

• We don’t cover routine physical exams, but the IPPE, AWV, or other Medicare benefits cover some routine physical elements
• Patients pay 100% out of pocket

View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure .

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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What is the Welcome to Medicare checkup?

 | You can get one free Welcome to Medicare checkup anytime during the first 12 months after you enroll in Medicare Part B , which is the part of Medicare that covers doctor visits and outpatient services. This checkup is not a comprehensive physical exam but is an opportunity for your doctor to assess your health and provide a plan of future care.

The Welcome to Medicare checkup is optional, but it serves as a baseline for monitoring your health during the annual wellness visits that Medicare will pay for in subsequent years. You do not need this checkup to qualify for later annual wellness visits, but Medicare won’t pay for a wellness visit during your first 12 months in Part B.

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What happens at the Welcome to Medicare checkup?

During the exam you can expect your doctor to do the following:

• Record your vital information, including blood pressure, height and weight.
• Calculate your  Body Mass Index (BMI).
• Review your health history — your own and that of your family.
• Determine your ability to function independently and your level of safety, such as how well you perform activities of daily living and your risk of falls.
• Assess your potential for depression.
• Check for risk factors that could indicate future serious illnesses.
• Provide a simple vision test.
• Recommend screenings, shots and other preventive services in writing that you may need to stay healthy. Many of these, such as mammograms and vaccinations, may be free under Medicare.
• Offer to talk about advance directives . A health care proxy lets you designate someone else to make medical decisions on your behalf if you can’t, and a living will specifies your preferences for medical treatment at the end of your life.

How can I prepare for my Welcome to Medicare visit?

To make the most of this appointment, you should gather the following information and records in advance:

• Your family medical history Learn as much as you can about your blood relatives’ health history. Any information you can give your doctor can help determine if you are at risk for inherited diseases.
• Your personal medical records That includes providing immunization records if you’re seeing a new doctor.
• Your prescription medications Along with listing the names of your drugs, include dosage, how often you take each medication and why.

How much will I pay for a Welcome to Medicare checkup?

You’ll have no deductible or copayment for the Welcome to Medicare checkup if you meet the following conditions:

If you’re enrolled in original Medicare, you need to go to a doctor who accepts “assignment,” meaning that the physician accepts the Medicare-approved amount as full compensation.

If you’re enrolled in a Medicare Advantage plan that has a provider network, such as an HMO or PPO , you may need to go to a doctor in the plan’s provider network.

Keep in mind

Even though you won’t have to pay for this checkup, the doctor could order other tests or procedures for which you may have to cover deductibles and copayments out of pocket.

Updated June 22, 2022

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Your “Welcome to Medicare” Visit Checklist

Written by Ari Parker — Updated: Tuesday, March 19, 2024

Check off what you should ask, what to schedule, and how to prepare for your “Welcome to Medicare” visit

Planning for health insurance and maintaining a regular schedule for doctor visits should be a priority for retirees. When you first enroll in Medicare, you have access to a free “Welcome to Medicare” preventive visit once within the first 12 months after you enroll in Part B.

This visit is a great opportunity to understand and take advantage of the preventive services covered by Medicare Part B. If you’re new to Medicare, we’ve prepared a checklist for you to get ready for your Welcome to Medicare visit.

Key takeaways:

If you’re new to Medicare, you have a free “Welcome to Medicare” visit once within the first 12 months after your Part B coverage starts. 

This visit is a good time to ask your provider about your health conditions, understand what preventive screenings and vaccines to schedule, and take control of your healthcare.

After your first 12 months of Part B coverage, you get one free “Wellness” visit each year .

What is the Welcome to Medicare visit?

For beneficiaries who are new to Medicare, the Welcome to Medicare visit is an opportunity to take control of your health by talking to your doctor about any concerns, reviewing your medical history, and understanding your options for preventive services that are covered by Medicare. This visit is free and you can schedule it within the 12 months after your Part B coverage begins.

Keep in mind that the Welcome to Medicare visit is not typically a comprehensive physical exam or a head-to-toe assessment. Instead, it focuses on preventive care and education to help you stay healthy and catch potential health issues early on.

While the visit itself won’t cost you a dime, you may have to pay a copay or coinsurance if your healthcare provider performs additional services during the same appointment. 

What to expect during the Welcome to Medicare visit

During the Welcome to Medicare visit, your doctor will typically review your medical history, assess your current health status, and provide personalized health advice and information, especially around preventive screenings. 

The visit may include:

Discussing your medical and family history

Measuring your height, weight, blood pressure, and other routine vitals

Assessing risk factors for certain diseases

Recommendations for preventive screenings

Reviewing which vaccinations you’ve received and recommendations for vaccinations you may need

Conducting a simple vision test

Referrals for care

Evaluating your mental health

Counseling on living a healthy lifestyle, including diet and exercise

Explaining the various preventive services covered by Medicare, such as screenings for cancer, cardiovascular disease, and diabetes

Consultation about creating advance directives (how you want to make medical decisions if you can’t speak for yourself)

The Welcome to Medicare visit empowers you to take charge of your healthcare by evaluating your current health and developing a plan for ongoing preventive care. 

Checklist one: preparing for the Welcome to Medicare visit

Compile your medical history: Be prepared to share your medical history with your healthcare provider, and include details about past and present medical conditions. Share details about surgeries, hospitalizations, and other major health events. Be ready to discuss any conditions that run in your family as well.

Make a list of your medications: Your doctor will ask you if you’re taking any medications currently. Make a comprehensive list of all the drugs you’re taking, including prescriptions, over-the-counter medications, and supplements. It’s helpful for your doctor to know the dosage, frequency, and reason for taking each medication too. 

Gather relevant health documents: You’ll need your Medicare card and any other insurance cards you have. If you have information about advance directives or living wills, you can bring that for discussion. Bring other relevant medical records in case they come in handy.

Prepare questions to ask your provider: Take some time to consider or write down questions you have about your health. This is a time for you to take care of your present and future health. Ask about what your doctor recommends for you to prevent or manage specific health concerns. 

Note any health concerns currently: Whether mental or physical, take note of symptoms you’ve been experiencing or recent changes in your health. Your doctor may also ask you about your daily habits, like exercise, diet, and sleep patterns. 

Checklist two: follow-up after the Welcome to Medicare visit

Review recommendations from your doctor: Take time to understand your doctor’s recommendations and then make a list of your next steps. It could be scheduling preventive screenings , booking an appointment for a vaccination, or implementing lifestyle changes. 

Schedule follow-up appointments: If your healthcare provider recommended any follow-up screenings or tests, schedule these appointments promptly. Avoid delays to catch and prevent conditions early on.

Update your medication list: Implement any medication changes into your routine if your doctor recommended changes to your prescriptions. Monitor for any side effects or challenges with the medication. 

Understand your Medicare benefits: Knowing your Medicare benefits for preventive care can help you prevent health challenges in the future. Medicare has comprehensive coverage for screenings, vaccines, and tests, so you can take full advantage of your coverage. You can also get one free “Wellness” visit each year .

Keep it up : Continue to implement lifestyle changes and schedule preventive measures. Routine doctor visits can also ensure that you live a long and healthy life. 

By following these checklists, you can play a proactive role in managing your health and ensuring that you receive timely care to maintain your well-being. 

If you have more questions about Medicare, you can ask your provider during your Welcome to Medicare visit or you can get in touch with a Chapter Medicare Advisor. An Advisor can help you thoroughly understand your plan so that you can use your benefits to their full extent.

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Initial Preventive Physical Examination

The Affordable Care Act provides for an initial preventive physician exam (IPPE) also known as the "Welcome to Medicare" preventative visit, for Medicare beneficiaries as of January 1, 2011. Medicare pays for one IPPE visit per lifetime that must be completed no later than 12 months after the patient’s Medicare Part B eligibility date. You should ensure your billing staff are aware of these services and how to bill for them. 

Coding and Billing an IPPE

• G0402: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
• G0403: Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report
• G0404: Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination
• G0405: Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination
• G0468: Federally qualified health center (FQHC) visit, IPPE, or AWV, a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving IPPE or AWV

For more details about how to bill these codes, see module 9 of Coding for Clinicians.

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Annual wellness visit, preventive services.

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The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical. Also, this service is similar to but separate from the one-time Welcome to Medicare preventive visit .

Eligibility

Medicare Part B covers the Annual Wellness Visit if:

• You have had Part B for over 12 months
• And, you have not received an AWV in the past 12 months

Additionally, you cannot receive your AWV within the same year as your Welcome to Medicare preventive visit.

Covered services

During your first Annual Wellness Visit, your PCP will develop your personalized prevention plan. Your PCP may also:

• Check your height, weight, blood pressure, and other routine measurements
• This may include a questionnaire that you complete before or during the visit. The questionnaire asks about your health status, injury risks, behavioral risks, and urgent health needs.
• This includes screening for hearing impairments and your risk of falling.
• Your doctor must also assess your ability to perform activities of daily living (such as bathing and dressing), and your level of safety at home.
• Learn about your medical and family history
• Medications include prescription medications, as well as vitamins and supplements you may take
• Your PCP should keep in mind your health status, screening history, and eligibility for age-appropriate, Medicare-covered preventive services
• Medicare does not require that doctors use a test to screen you. Instead, doctors are asked to rely on their observations and/or on reports by you and others.
• Screen for depression
• Health education and preventive counseling may relate to weight loss, physical activity, smoking cessation, fall prevention, nutrition, and more.

AWVs after your first visit may be different. At subsequent AWVs, your doctor should:

• Check your weight and blood pressure
• Update the health risk assessment you completed
• Update your medical and family history
• Update your list of current medical providers and suppliers
• Update your written screening schedule
• Screen for cognitive issues
• Provide health advice and referrals to health education and/or preventive counseling services

If you qualify, Original Medicare covers the Annual Wellness Visit at 100% of the Medicare-approved amount when you receive the service from a participating provider . This means you pay nothing (no deductible or coinsurance ). Medicare Advantage Plans are required to cover AWVs without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s eligibility requirements for the service.

During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit.

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Doctor Visits

Get Your Medicare Wellness Visit Every Year

Take Action

If you have Medicare, be sure to schedule a yearly wellness visit with your doctor or nurse. A yearly wellness visit is a great way to help you stay healthy.

What happens during a yearly wellness visit?

First, the doctor or nurse will ask you to fill out a questionnaire called a health risk assessment. Answering these questions will help you get the most from your yearly wellness visit.

During your visit, the doctor or nurse will:

• Go over your health risk assessment with you
• Measure your height and weight and check your blood pressure
• Ask about your health history and conditions that run in your family 
• Ask about other doctors you see and any medicines you take
• Give advice to help you prevent disease, improve your health, and stay well
• Look for any changes in your ability to think, learn, or remember
• Ask about any risk factors for substance use disorder and talk with you about treatment options, if needed

If you take opioids to treat pain, the doctor or nurse may talk with you about your risk factors for opioid use disorder, review your treatment plan, and tell you about non-opioid treatment options. They may also refer you to a specialist. 

Finally, the doctor or nurse may give you a short, written plan to take home. This plan will include any screening tests and other preventive services that you’ll need in the next several years. Preventive services are health care services that keep you from getting sick. 

Learn more about yearly wellness visits .

Plan Your Visit

When can i go for a yearly wellness visit.

You can start getting Medicare wellness visits after you’ve had Medicare Part B for at least 12 months. Keep in mind you’ll need to wait 12 months in between Medicare wellness visits.

Do I need to have a “Welcome to Medicare” visit first?

You don’t need to have a “Welcome to Medicare” preventive visit before getting a yearly wellness visit.

If you choose to get the “Welcome to Medicare” visit during the first 12 months you have Medicare Part B, you’ll have to wait 12 months before you can get your first yearly wellness visit. 

Learn more about the “Welcome to Medicare” visit .

What about cost?

With Medicare Part B, you can get a wellness visit once a year at no cost to you. Check to make sure the doctor or nurse accepts Medicare when you schedule your appointment.

If you get any tests or services that aren’t included in the yearly wellness visit (like an extra blood test), you may have to pay some of those costs.

Who Can Get Medicare?

Medicare is a federal health insurance program. You may be able to get Medicare if you:

• Are age 65 or older
• Are under age 65 and have a disability
• Have amyotrophic lateral sclerosis (ALS), also called Lou Gehrig's disease
• Have permanent kidney failure (called end-stage renal disease)

You must be living in the United States legally for at least 5 years to qualify for Medicare.  Answer these questions to find out when you can sign up for Medicare .

Make an Appointment

Take these steps to help you get the most out of your Medicare yearly wellness visit.

Schedule your Medicare yearly wellness visit.

Call your doctor’s office and ask to schedule your Medicare yearly wellness visit. Make sure it’s been at least 12 months since your last wellness visit.

If you're looking for a new doctor,  check out these tips on choosing a doctor you can trust .  

To find a doctor who accepts Medicare:

• Search for a doctor on the Medicare website
• Call 1-800-MEDICARE (1-800-633-4227)
• If you use a TTY, call Medicare at 1-877-486-2048

Gather important information.

Take any medical records or information you have to the appointment. Make sure you have important information like:

• The name and phone number of a friend or relative to call if there’s an emergency
• Dates and results of checkups and screening tests
• A list of vaccines (shots) you’ve gotten and the dates you got them
• Medicines you take (including over-the-counter medicines and vitamins), how much you take, and why you take them
• Phone numbers and addresses of other places you go to for health care, including your pharmacy

Make a list of any important changes in your life or health.

Your doctor or nurse will want to know about any big changes since your last visit. For example, write down things like:

• Losing your job
• A death in the family
• A serious illness or injury
• A change in your living situation

Know your family health history.

Your family's health history is an important part of your personal health record.  Use this family health history tool  to keep track of conditions that run in your family. Take this information to your yearly wellness visit.

Ask Questions

Make a list of questions you want to ask the doctor..

This visit is a great time to ask the doctor or nurse any questions about:

• A health condition
• Changes in sleeping or eating habits
• Pain or discomfort
• Prescription medicines, over-the-counter medicines, or supplements

Some important questions include:

• Do I need to get any vaccines to protect my health?
• How can I get more physical activity?
• Am I at a healthy weight?
• Do I need to make any changes to my eating habits?

Use this question builder tool  to make a list of things to ask your doctor or nurse.

It can be helpful to write down the answers so you remember them later. You may also want to take a friend or relative with you for support — they can take notes, too.

What to Expect

Know what to expect at your visit..

The doctor or nurse will ask you questions about your health and safety, like:

• Do you have stairs in your home?
• What do you do to stay active?
• Have you lost interest in doing things you usually enjoy?
• Do you have a hard time hearing people on the phone?
• What medicines, vitamins, or supplements do you take regularly?

The doctor or nurse will also do things like:

• Measure your height and weight
• Check your blood pressure
• Ask about your medical and family history

Make a wellness plan with your doctor.

During the yearly wellness visit, the doctor or nurse may give you a short, written plan — like a checklist — to take home with you. This written plan will include a list of preventive services that you’ll need over the next 5 to 10 years.

Your plan may include:

• Getting important screenings for cancer or other diseases
• Making healthy changes, like getting more physical activity

Follow up after your visit.

During your yearly wellness visit, the doctor or nurse may recommend that you see a specialist or get certain tests. Try to schedule these follow-up appointments before you leave your wellness visit.

If that’s not possible, put a reminder note on your calendar to schedule your follow-up appointments.

Add any new health information to your personal health documents.

Make your next wellness visit easier by updating your medical information in the personal health documents you keep at home. Write down any vaccines you got and the results of any screening tests.

Medicare offers an online tool called  MyMedicare  to help you track your personal health information and Medicare claims. If you have your Medicare number, you can  sign up for your MyMedicare account now .

Healthy Habits

Take care of yourself all year long..

After your visit, follow the plan you made with your doctor or nurse to stay healthy. Your plan may include:

• Getting important screenings
• Getting vaccines for older adults
• Keeping your heart healthy
• Preventing type 2 diabetes
• Lowering your risk of falling

Your plan could also include:

• Getting active
• Eating healthy
• Quitting smoking
• Watching your weight

Content last updated February 9, 2023

Reviewer Information

This information on Medicare wellness visits was adapted from materials from the Centers for Medicare and Medicaid Services

Reviewed by: Rachel Katonak Centers for Medicare and Medicaid Services Division of Policy and Evidence Review Coverage and Analysis Group

November 2022

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What kind of plan are you looking for?

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• Medical and/or drug

Directing to payment site

We’re bringing you to our trusted partner to help process your payments. This site has its own log in. It may be different from your Aetna secure member site log in.

*For plans that include Resources For Living benefit

Resources For Living is not available for members with Aetna Part D (prescription only) plans, Dual Eligible Special Needs Plans (D-SNPs), Institutional Special Needs Plans (I-SNPs) or Medicare Supplement plans.

*For member example stories

These examples are based on the actual experiences of members who have used Resources For Living. We’ve changed their names and some details to help protect their identities.