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January 2020

Get ready for annual visits for your MA patients

Now that we’re embarking on a new year, you’ll start seeing new and existing patients who have Medicare Advantage plans (either Medicare Plus BlueSM PPO or BCN AdvantageSM) for their “welcome to Medicare” visits, annual wellness visits or routine physical exams. To help you prepare, we want to share this important information about these different visits:

  • New Medicare Advantage members should be scheduling their “welcome to Medicare” preventive visit, also known as the initial preventive examination, and their routine physical exams.
  • Existing Medicare Advantage members should begin scheduling their annual wellness visit and their routine physical exams.

Welcome to Medicare visit
The “welcome to Medicare” preventive visit is sometimes referred to as the initial preventive examination. This is a one-time appointment for new Medicare patients to be scheduled within their first 12 months of enrollment. Medicare pays for one “welcome to Medicare” visit per member, per lifetime.

This visit is a great way to get up-to-date information on health screenings, shot records, family medical history and other preventive care services for your patients. These visits can be scheduled at the same time or coordinated with the patient’s routine physical exam to get the best picture of your patient’s health.
The “welcome to Medicare” visit will include a health risk assessment and self-reported information from your patient to be completed before or during the visit. For more information about health risk assessments, see the Framework for Patient-Centered Health Risk Assessments** on the Centers for Disease Control and Prevention website.

During the “welcome to Medicare” visit, you should:

  • Perform a health risk assessment
  • Record your patient’s medical and social history (such as alcohol or tobacco use, diet and activity level)
  • Check height, weight and blood pressure
  • Calculate body mass index
  • Perform a simple vision test
  • Review potential risk for depression and patient level of safety
  • Offer to talk about creating advance directives
  • Educate the patient on preventive services needed and prescribe appropriate services
  • Create a screening schedule (checklist) for appropriate preventive services
Billing code for “welcome to Medicare” visit, also called initial preventive physical examination
G0402

Annual wellness visit
The annual wellness visit is a chance for you to develop or update your patient’s personalized prevention plan based on his or her current health situation and risk factors. Health risk assessments are also part of the annual wellness visit. The assessment consists of self-reported information from your patient to be completed before or during the visit.

Medicare will cover an annual wellness visit every 12 months for patients who’ve been enrolled in Medicare for longer than 12 months. Patients can schedule their annual wellness visit on the same day or coordinate it with their routine physical exam (see below) to help give you a complete view of their health.

Services at the annual wellness visit include:

  • Health risk assessment
  • Review of medical and family history
  • Develop or update a list of current providers and prescriptions
  • Height, weight, blood pressure and other routine measurements
  • Detection of any cognitive impairment
  • Personalized health advice
  • A list of risk factors and treatment options
  • Education on preventive services needed and prescribe appropriate services
  • A review and update of the screening schedule (checklist) for appropriate preventive services
  • Advance care planning
Billing codes for annual wellness visits, which include a personalized prevention plan of service
G0438 — First annual wellness visit, can only be billed one time, 12 months after  G0402 (initial preventive physical exam)
G0439 — Annual wellness visit (subsequent)
Note: G0438 or G0439 must not be billed within 12 months or previous billing of G0402 (initial preventive physical exam)

Routine physical exam
The routine physical exam is typically covered annually by the patient’s Medicare Advantage health care plan. These exams are part of preventive services that aren’t part of the welcome to Medicare visit or annual wellness visit.

Routine physical exams are used to get information about the patient’s medical history and family history, perform a head-to-toe assessment with a hands-on exam to assess your patient’s health and address any abnormalities or signs of disease. Routine physical exams should include the following:

  • A visual inspection
  • Palpitation
  • Auscultation
  • Manual examination
Billing codes for annual exams or physicals:
New patient
*99386 (40 to 64 years old)
*99387 (65 years and older)
Established patient
*99396 (40 to 64 years old)
*99397 (65 years and older

Care plans
These preventive visits are an excellent opportunity for you and your patients to plan their care for the year. Care plans should include a schedule for preventive services and health screenings, many of which are required annual services to meet Healthcare Effectiveness Data and Information Set, or HEDIS®, specifications.

You’ll need to recommend and prescribe needed preventive services that apply to his or her care plan or refer your patient to an appropriate provider. Some examples of preventive services include:

  • Colon cancer screening
    • FOBT yearly
    • Sigmoidoscopy every five years
    • Colonoscopy every 10 years
    • Cologuard every three years
  • Breast cancer screening
    • Mammography every two years
  • Osteoporosis screening
    • Bone mineral density testing for women over age 65 and men over age 70 two years — every two to 10 years, depending on risk factors. Note: Medicare pays for the screening every two years — more often if medically necessary.
  • Comprehensive diabetes care
    • A1c blood sugar screening to diagnose diabetes — every three years if test is normal. Once diagnosed, two to four times per year to monitor treatment response
    • Urine microalbumin screening — yearly
    • Retinal eye exam — every other year if negative or every year if positive

These visits also provide an opportunity to review or create a risk assessment for your patients, including a full list of their long-term chronic conditions. This will help your patients take advantage of disease and care management programs, as well as prevention initiatives.

These visits benefit both you and your patient by:

  • Uncovering care management opportunities
  • Identifying practice patterns
  • Managing patient medications better
  • Reducing avoidable hospital admissions

For more information on risk adjustment and HEDIS best practices, refer to our online provider manuals.

Note: BCN Advantage only reimburses one evaluation and management code on a date of service.

HEDIS® is a registered trademark of the National Committee for Quality Assurance.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.