Healthcare.gov defines preventive services as “Routine healthcare that includes screenings, checkups, and patient counseling to prevent illnesses, disease, or other health problems.” Healthcare providers, insurers, and patients often view preventive services as long-term investments in people’s health. The earlier chronic disease indicators are caught and addressed, the healthier and longer patients may live. For example, the provision of preventive services that target cardiovascular disease alone has the potential to save tens of thousands of lives each year.
The most effective way to keep patients healthier for longer is to prevent the onset or further progression of chronic disease. For example, obesity is often a catalyst for other chronic conditions. However, patients who can decrease their body mass index through lifestyle changes — like increasing their physical activity or making healthier food choices — can often lower their risk for chronic disease significantly. During regularly scheduled preventive services, patients can learn about their chronic disease risk factors, how these factors may negatively impact their future health, and how they can course correct to live a longer, healthier life.
Keeping people healthy is not only best for the patient’s wellbeing, but it is also more cost-effective than treating the symptoms of an illness that has already developed. Thus, a key strategy to reducing the economic strain of chronic illness is prevention.
For example, according to the American Journal of Managed Care, patients who took part in Medicare’s annual wellness visits (AWV) experienced a nearly 6% reduction in total healthcare costs over the following 11-month period. With more than 60 million Medicare beneficiaries, organizations that make preventive services an important part of their care can potentially deliver substantial cost savings to patients and achieve significant savings of their own that will enhance the amount of money organizations can keep from their value-based care arrangements.
One of the most significant results of the Affordable Care Act (ACA), enacted in March 2010, was increasing access to preventive services while mitigating rising out-of-pocket costs. When provided by in-network practitioners, preventive services typically receive 100% coverage and at no expense to the patient. Through annual wellness visits, Medicare embraced preventive care cost savings early on. The AWV provides an opportunity for practitioners to connect with patients, evaluate chronic disease risk factors, and create an ongoing preventive screening plan. As of 2022, the average reimbursement for an AWV is between $132 and $170, thus illustrating how organizations promote patient wellness while simultaneously generating recurring revenue. Adding advance care, depression, alcohol, obesity, and other appropriate screenings and interventions to the AWV can increase this reimbursement to more than $300 per visit while providing patients with even more helpful services.
Alternative payment models — such as the merit-based incentive payment system, pay-for-performance, or other advanced payment models — can pose risks for practitioners when unhealthy patients contribute to higher expenses that then lead to lower overall reimbursement. However, if practitioners are meeting specific metrics for patient health and satisfaction and the quality of care provided, these payment models reward practitioners beyond typical fee-for-service reimbursement. Payers are interested in making money, and the best way for them to do so is with healthier patients who require fewer covered (i.e., reimbursable) services.
How do practitioners and insurers know what screenings and treatments are considered preventive services? The U.S. Preventive Services Task Force (USPSTF), created in 1984, exerts significant influence by helping to recommend and determine the most beneficial and effective clinical preventive services.
Guided by its goal to positively impact the health of all Americans, USPSTF reviews and updates existing clinical preventive service guidelines and evaluates new preventive service recommendations. As a result of USPSTF’s diligence, practitioners have access to the most reliable and current clinical prevention tactics available. Note: To access the Preventive Services Task Force list of published recommendations, click here.
Following are six elements of USPSTF that describe how it conducts its critically important work.
Despite the effectiveness of preventive care, many clinicians are still struggling to deliver this relatively inexpensive solution. Why? Some believe that payers are over-incentivizing reactive care, rewarding care volume (i.e., fee-forservice) and thus making the provision of preventive services difficult. Others say that patients aren’t always aware of their eligibility to receive such care and often at no cost. Another reason put forth is that the overabundance of chronically ill people who seek treatment makes it difficult for practitioners to flip the healthcare paradigm to a preventive care model. Most likely, all the above factor into the underutilization of preventive services. In fact, the Centers for Disease Control and Prevention (CDC) supports this notion, citing a lack in implementation on the behalf of practitioners.
Although preventive care is encouraged by government policy and insurance providers, there are many challenges when it comes to implementing a preventive screening program in a traditional medical practice. The following are several common hurdles:
Allowing patients to complete forms or assessments in a digital environment — even prior to their office visit — increases efficiency. Digital forms can be integrated into and with other medical software, which cuts back on administrative processing time, decreases the likelihood of missed information, and reduces the risk of human data entry errors.Advance care planning (ACP) can be a difficult subject to broach with patients. Yet, it is extremely important because it enables them to make informed decisions about the healthcare they want to receive as they reach the final stages of their lives. Let’s take a closer look at ACP.
ACP services give patients an opportunity to share their preferences with their provider and loved ones about the care they wish to receive when they are no longer able to express their preferences themselves. This includes selecting a healthcare proxy who can make decisions on the patient’s behalf should they become incapacitated. ACP services may even lower the cost of healthcare in general as they can avoid expensive life-prolonging therapies that a patient does not want to receive.
For several years now, Medicare has been reimbursing qualified healthcare professionals for ACP services provided to Medicare-eligible patients, both during the provision of the annual wellness visit and as a standalone visit. Although the ACP discussion is voluntary and can be conducted anytime, if the service is performed during the patient’s AWV, the patient incurs no costs. However, if ACP services are performed outside of the AWV visit, the patient will likely be expected to cover any copay, coinsurance, and deductible.
Unlike the AWV, the number of ACP visits per patient is not limited annually. As a patient’s health needs change, updating their advance directives to reflect those changes is prudent.
Since primary care providers (PCPs) and their patients are often more connected than patients are with their specialists, PCPs are uniquely situated to initiate ACP discussions. Conversations about advance care planning should take place in person and include the following:
During the advance care planning visit, thorough documentation concerning the patient’s advance directives and end-of-life wishes should be completed. This documentation should contain actionable orders that can be easily understood by family and healthcare professionals so that the patient’s wishes can be accurately interpreted and followed.
Since the billing and coding guidelines surrounding advance care planning are complex, many providers may be having ACP conversations with their patients but missing out on a reimbursement opportunity. Scheduling and time constraints are just two of the challenges that can prevent providers from directly scheduling ACP appointments. Often, ACP appointments require more than 15 minutes, which makes impromptu ACP conversations difficult and the required documentation even more daunting.
Providers can overcome these hurdles by changing workflows and providing more patient education about advance care planning services before scheduling the visit. Patients who receive educational materials in advance of their appointment are better able to discuss sensitive issues and prepare their plan before the appointment, which can save time. Medical software with an ACP component can also play a valuable role in tackling the logistics of providing and documenting ACP services by helping ensure each visit is complete and completed properly and by helping eliminate human error in meeting all the requirements.
According to a recent Medscape report, less than 3% of qualifying medical providers are conducting and billing for ACP services. When performed and documented correctly, ACP can be billed in addition to an AWV or in addition to other visits, such as evaluation and management services (E/M services). As of 2022, the two primary ACP CPT codes are CPT 99497 and CPT 99498 and pay the provider around $86 for the first 30 minutes of face-to-face time and another ~$75 for each additional 30 minutes. Remember: advance care planning can be updated and billed as many times as necessary to ensure a current reflection of the patient’s health and advance directive wishes.
Now let’s focus on one particular — and particularly important — preventive service: depression screening.
Depression can be a silent illness. Individuals often don’t realize that the symptoms they are experiencing — such as changes in sleeping habits, weight gain, unexpected weight loss, back pain, or headaches — are common indicators of depression. Since the symptoms of depression can vary greatly from patient to patient, people often visit their PCP without realizing physical ailments may be caused by a psychological condition. Thus, PCPs are well-positioned to be the first to recognize and diagnose depression in their patients.
According to the CDC, 15%-20% of the U.S. population aged 65 years and over has experienced depression at least once in their lifetime. Compounding the issue of depression in older Americans is chronic illness. When chronic illness and depression co-exist, healthcare costs sharply increase for an already vulnerable population. Older adults face changing life circumstances that can lead to depression, such as the passing of a spouse or partner, losing their independence due to physical decline, or the end of a rewarding career. For PCPs, depression screenings are critical in this demographic so that potential mental health issues can be identified early and successfully treated.
According to the American Psychiatric Association, PCPs are conducting depression screenings for less than 5% of adults. Clearly, depression is severely underdiagnosed and undertreated in older populations.
Fortunately, USPSTF and Medicare have identified the benefit of depression screenings, and as such, Medicare covers a co-pay waived annual depression screening for all beneficiaries. Many private insurers have also started covering these screenings. Medicare has also added annual depression screenings to its MACRA/MIPS program, which means that Medicare payment modifiers could be increased through the implementation of depression screenings.
Screening for depression in a primary care setting should be conducted using a validated instrument and can be billed as a standalone service. Depression screening is considered ‘bundled’ within a welcome to Medicare physical (G0402) or initial annual wellness visit (G0438) but can be billed concurrently with a subsequent AWV (G0439). It’s not always easy to add a new process to established clinical workflows, bit implementing comprehensive wellness software can help automate these processes for depression and other behavioral health screenings.
For practices seeking to expand their offerings, the following information is essential for understanding the preventive services Medicare covers.
Per Medicare guidelines, practitioners should work with their Medicare patients to determine whether these patients should receive the preventive services and screenings listed below. Most of these services are reimbursable to the rendering practitioner and usually fully covered by Medicare with no out-of-pocket expense to the patient.
They can be broken down as follows:
As mentioned earlier, the Medicare annual wellness visit (AWV) is an annual appointment during which a patient meets with a clinical staff member to develop or update a personalized prevention plan. This plan is based on a patient’s current health and risk factors, with the goal of preventing disease. Not only does the AWV offer opportunities for the provision of preventive services, but it also allows for the creation of a future schedule of preventive services.
Medicare Part B covers many preventive services in full, meaning Medicare beneficiaries will not incur out-of-pocket expenses (co-payment or deductible) when they receive the services. Fully covered preventive services include those listed above as well as diabetes screening (up to twice per year for those patients at high risk of diabetes) and hepatitis C screening test (for those patients at high risk). Some preventive services that are likely to require cost-sharing by the beneficiary include a diagnostic mammogram, digital rectal exam for prostate cancer, and glaucoma test.
If patients seek treatment from providers who do not accept the preventive services assignment and/or if they are enrolled in a Medicare health plan or have other insurance, they may pay more out of pocket. Patients will also pay more if they exceed the covered frequency of a preventive service.
It is worth noting again the financial value for providing organizations that offer the Medicare AWV. As of 2022, practices receive around $170 per initial AWV and $133 per subsequent AWV. When the necessary preventive services are provided at the same time as the AWV, that number increases.
Even when looking at the frequency of eligibility conservatively, Medicare patients who receive a full suite of preventive services could drive up practice revenue by more than $360 annually per patient. If 50 patients receive the full suite, practices could see $18,000 in annual reimbursement. In addition, with many patients, these services can be provided during just one AWV.
Below is a breakdown of the 2022 average reimbursement for a few preventive services commonly performed with the Medicare AWV, per the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule:
| $86 Advance care planning |
$19 Annual depression screening |
$27 Cardiovascular risk counseling |
$27 Obesity counseling |
Note: Figures are rounded to nearest dollar amount based on national averages.
To verify patient eligibility for preventive services, practices must determine the last date that their patients received such services. Practices have two options for verification of this information:
Due to its regulatory and statutory authority, CMS can add coverage through the National Coverage Determination process if the service meets the following criteria:
Private insurers typically follow Medicare’s lead when new services are added. In fact, private payers are legally required to cover many services that USPSTF deems beneficial.
Keeping track of what services need to be scheduled can be daunting for patients, especially when the timing of one preventive service is different than another (e.g., monthly rather than annually).
Technological tools can provide electronic reminders, and Medicare’s downloadable “Are You Up-To-Date on Your Preventive Services?” checklist is a helpful resource for patients.
When the Affordable Care Act took effect in 2010, it expanded access to preventive care for millions of Americans by mandating that all non-grandfathered health plans cover preventive services for their members as long as those services are provided at the requisite time by an in-network practitioner. Initially, some payers were concerned about the financial impacts to their business. Ultimately, the significant cost savings for insurers and the entire healthcare system has encouraged them to come around and recognize the importance of preventive services for the American public.
Following are ACA preventive services, corresponding current procedural terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes and descriptions, as well as patient eligibility. Since services may be added by USPSTF as it continues to review the latest medical research, this list can change.
The American Medical Association has estimated that about 5% of claims lines are denied by Medicare. Denials can lead to increased days in accounts receivable (A/R), write-off rates, and overall cost to collect, among other headaches for providing organizations. To better ensure that your annual wellness visit (AWV) claims are not denied, proper coding is essential. Not only does accurate coding ensure that practices receive proper reimbursements, but it also protects against penalties incurred from failed coding audits.
G0438 is the HCPCS code that should be used for a patient’s first annual wellness visit. Its long descriptor is “Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit,” while its short descriptor is “Annual wellness first.”
Two key things to know about G0438:
Medicare pays for a single initial AWV per beneficiary per lifetime.
G0439 is the HCPCS code that should be utilized for all subsequent annual wellness visits. Its long descriptor is “Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit,” while its short descriptor is “Annual wellness subseq.”
That said, keep mind that if a practice takes on a new Medicare beneficiary and is providing that patient their first annual wellness visit, practitioners must determine if the beneficiary had an initial AWV provided by another organization. If so, the G0439 code would be used, not G0438 since G0438 was already billed by the other organization that provided the AWV service.
Broadly speaking, IPPE, also known as the “Welcome to Medicare Visit,” takes place when a practitioner reviews a Medicare beneficiary’s medical and social health history as well as offers education on preventive services. Medicare pays for a single beneficiary IPPE per lifetime that must furnished no later than the first 12 months after the beneficiary’s eligibility date for Medicare Part B benefits.
G0402 is the HCPCS code that should be used for the IPPE. Its long descriptor is “Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment,” while its short descriptor is “Initial preventive exam.”
Beyond the primary visit codes — HCPCS G0402, HCPCS G0438, and HCPCS G0439 — practitioners may use other codes to bill for services performed during a Welcome to Medicare Visit or AWV. If those additional codes are used, practitioners must include a note that supports the need for each service provided.
Many of these codes have guidelines that require them only to be used with specific visits after meeting certain criteria. For example, HCPCS G0444, used for a 15-minute annual depression screening, can only be added to subsequent wellness visits that are billed under G0439. If that specific code is used with the IPPE or initial AWV, it will be rejected. An abdominal aortic aneurysm (AAA) screening, coded as G0389, can only be provided with the IPPE code G0402 because it is ineligible to be used during AWVs.
Advance care planning (CPT 99497) is considered an optional element of the AWV but is considered a preventive service (and thus has its co-pay waived) when billed on the same day as an AWV with modifier -33.
HCPCS G0442 and HCPCS G0443 are additional codes that must be used in conjunction with each other to be valid. HCPCS G0442 is used for an annual alcohol screening, which should take approximately 15 minutes. G0443 is for 15-minute sessions of alcohol counseling. According to the Centers for Medicare & Medicaid Services, the screening service is required to occur prior to approval for a G0442. Thus, if a practitioner uses G0443 and no claims have been filed for G0442 in the preceding 12 months, the screening code will be denied.
Fifteen-minute obesity counseling sessions may be billed in conjunction with IPPE visits or AWV using HCPCS G0447. When wellness visits last longer than what is typical, prolonged preventive service codes designate a visit takes 30 minutes (G0513) or 60-plus minutes (G0514) past the typical duration of the service.
Our guide offers essential information and everything you need to know about understanding and getting paid for preventative services.
