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    v1.0.28
    OpenPayerPolicy UpdatesPreventive Services & ScreeningFlorida Blue AWV IPPE Coverage Update | OpenPayer
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    CurrentFlorida BluePolicy N/A

    Annual Wellness Visit (AWV) and Related Preventive Visit Coverage Criteria

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    Defines coverage, frequency, components, eligible providers, and billing guidance for the Medicare Annual Wellness Visit and related preventive examinations for Florida Blue members.

    Policy Summary
    PayerFlorida Blue
    PolicyAnnual Wellness Visit (AWV) and Related Preventive Visit Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument a complete Health Risk Assessment, personalized prevention plan, and meet time/documentation requirements to support AWV billing and any separately reportable E/M service (use modifier -25 when applicable).
    SourceLink

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    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1AWV/IPPE visits allowed per member per calendar year
    OnceIPPE and initial AWV reporting limitation
    G0438/G0439/G0402Key HCPCS codes
    30mMin total time for time-based E/M
    PA/ARNP/PhysicianAuthorized provider types

    Coverage Criteria for AWV and Preventive Visits

    Covered Preventive Visit Categories

    Covered when applicable conditions below are met:

    IPPE (G0402): Covered for new Medicare beneficiaries within the first 12 months of enrollment and includes medical/social history, preventive education, and specified screening (ECG codes G0403–G0405 when performed).one-time during first 12 months

    IPPE is a one-time service for a beneficiary

    First Annual Wellness Visit (G0438): Covered for beneficiaries with Medicare Part B longer than 12 months; includes a complete Health Risk Assessment (HRA), medical and family history, measurements, cognitive assessment, a personalized prevention plan of service (PPS), and optional social determinants of health assessment.first AWV billed once per lifetime

    Documentation of HRA and PPS required

    Subsequent Annual Wellness Visit (G0439): Covered annually (one per calendar year) and includes updating the HRA, medical/family history, measurements, cognitive and functional assessments, and updating the personalized prevention plan.one per calendar year

    Visits are limited to one per calendar year across providers

    Preventive Medicine / Routine Physical Exams (CPT 99385–99387; 99395–99397): Covered when performed as a comprehensive preventive medicine evaluation including age- and gender-appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and ordering of laboratory/diagnostic procedures.use age-group specific CPT codes

    Use listed CPT codes by patient age and new/established status

    Coverage for Routine Physical / AWV

    Routine physical exams and AWVs are covered when performed by authorized provider types and billed with appropriate codes, meeting documentation and time-based requirements when applicable.

    Provider and code requirements: Visit is performed by an authorized provider (physician, ARNP/NP, or physician assistant) AND billed with the appropriate CPT or HCPCS code based on patient age and new/established status (99385–99387 or 99395–99397 for routine physicals; G0438/G0439 or G0402 for AWV/IPPE as applicable).

    See coding groups for exact codes

    Documentation and time-based coding: All required elements and components of the exam must be documented. If selecting an E/M code based on total time on the date of the encounter, total time must meet or exceed 30 minutes. When separate problem-focused care is provided in the same encounter, document the separate management to support reporting an E/M with modifier -25 as appropriate.30 minutes when time-based

    Failure to document may affect coding and coverage

    Florida Blue allows one preventive visit per member per calendar year for either the IPPE or an Annual Wellness Visit (initial or subsequent). Visits in excess of this one-per-calendar-year limit will not be allowed (Reason: "Annual Wellness Visit Limit Exceeded"). In addition, the IPPE and the initial AWV may each be reported only once per lifetime. These frequency rules apply across providers (a service billed by one provider in the year prevents a second provider from billing the same service for that member in the same calendar year).

    No explicit exclusions are listed in the provided excerpt. The document includes coding examples and guidance but does not enumerate any service-level exclusions in this portion of the policy.

    No specific not medically necessary (NMN) conditions are stated in the excerpt provided. The references and examples included are informational and do not define any NMN determinations in this section.

    Coding and Billing Guidance

    IPPE-related HCPCSHCPCSCovered
    G0402Initial preventive physical examination; face-to-face visit; services limited to new beneficiary during the first 12 months of Medicare enrollment
    G0403Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report
    G0404Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination
    G0405Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination
    G0468Federally qualified health center (FQHC) visit; initial preventive physical exam (IPPE) or annual wellness visit (AWV)
    AWV HCPCS CodesHCPCSCovered
    G0438Annual wellness visit includes a personalized prevention plan of service (PPS), initial visit (AWV)
    G0439Annual wellness visit includes a personalized prevention plan of service (PPS), subsequent visit
    Preventive Medicine / Routine Physical CPT Codes by Age Group (initial/new and subsequent/established)CPTCovered
    99385Preventive medicine counseling and/or risk factor reduction intervention; initial comprehensive (age 18-39)
    99386Preventive medicine counseling and/or risk factor reduction intervention; initial comprehensive (age 40-64)
    99387Preventive medicine counseling and/or risk factor reduction intervention; initial comprehensive (age 65+)
    99395Periodic comprehensive preventive medicine re-evaluation and management (age 18-39)
    99396Periodic comprehensive preventive medicine re-evaluation and management (age 40-64)
    99397Periodic comprehensive preventive medicine re-evaluation and management (age 65+)
    Diagnosis Codes GuidanceICD-10
    Z00-Z99Range of encounter codes appropriate for preventive visits; a specific diagnosis is not required for IPPE/first AWV but a code from this range or one addressed during the visit may be used
    Routine Physical Exam CPT CodesCPTCovered
    99385Initial comprehensive preventive medicine evaluation, 18-39 years
    99386Initial comprehensive preventive medicine evaluation, 40-64 years
    99387Initial comprehensive preventive medicine evaluation, 65 years and older
    99395Periodic comprehensive preventive medicine re-evaluation, 18-39 years (established)
    99396Periodic comprehensive preventive medicine re-evaluation, 40-64 years (established)
    99397Periodic comprehensive preventive medicine re-evaluation, 65 years and older (established)
    AWV / IPPE and E/M CodesmixedCovered
    G0438Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit
    G0439Annual wellness visit; includes a personalized prevention plan of service (PPS), subsequent visit
    G0402Initial preventive physical examination; face-to-face visit; services limited to new beneficiary during the first 12 months of Medicare enrollment
    99214Office or other outpatient visit for the evaluation and management of an established patient; moderate level of medical decision making
    Time-based E/M coding threshold (>= 30 minutes)
    Time thresholdTotal time on date of encounter must be >= 30 minutes when using time for E/M code selection
    Applies toAll preventive visit types when using total time for code selection (IPPE, AWV, Routine Physical)
    Documentation noteWhen reporting a separate, significant E/M with modifier -25, total time must meet the 30-minute threshold and documentation must support medical necessity

    Provider Actions, Documentation, and Billing Notes

    Billing Rule

    HCPCS Reporting

    Report the appropriate HCPCS for IPPE, initial AWV, subsequent AWV, and FQHC visits when applicable. No prior authorization is indicated in this excerpt — ensure correct HCPCS is billed to reflect the service provided.

    • G0402 — Initial preventive physical examination (IPPE)
    • G0403 — ECG with interpretation and report (screening for IPPE)
    • G0404 — ECG tracing only (screening for IPPE)
    • G0405 — ECG interpretation/report only (screening for IPPE)
    • G0438 — Annual wellness visit, initial (PPS)
    • G0439 — Annual wellness visit, subsequent (PPS)
    • G0468 — FQHC visit; IPPE or AWV
    Billing Rule

    Routine preventive visit codes

    Definitions and Key Terms

    Health Risk Assessment (HRA)
    DefinitionPatient self-reported instrument collecting demographic data, health status self-assessment, psychosocial and behavioral risks, instrumental activities of daily living (IADLs), and other factors to inform the personalized prevention plan
    ComponentsDemographic data; health status self-assessment; psychosocial risks (life satisfaction, stress, depression/suicidality, fatigue); behavioral risks (tobacco, alcohol, physical activity, home safety); IADLs
    Update timingThe provider or the patient can update the HRA before or during the AWV
    Initial Preventive Physical Examination (IPPE / 'Welcome to Medicare')
    DefinitionA one-time initial preventive visit (Welcome to Medicare) for new Medicare beneficiaries within the first 12 months of Part B enrollment that includes evaluation of medical and social history, education on preventive services, and limited screening

    Background

    The Annual Wellness Visit (AWV) is a preventive service focused on reviewing the beneficiary's medical and family history, assessing current health status including cognitive and functional status, and completing a Health Risk Assessment (HRA). The AWV is used to develop or update a personalized prevention plan and may include measurements, counseling, anticipatory guidance, optional social determinants of health screening, and advance care planning as appropriate. It is intended for Medicare Part B beneficiaries beyond their first 12 months of enrollment and requires documentation of the HRA and the personalized prevention plan to support the service.

    Policy Summary
    PayerFlorida Blue
    PolicyAnnual Wellness Visit (AWV) and Related Preventive Visit Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument a complete Health Risk Assessment, personalized prevention plan, and meet time/documentation requirements to support AWV billing and any separately reportable E/M service (use modifier -25 when applicable).
    SourceLink
    On This Page
    Coverage Criteria for AWV and Preventive VisitsCoding and Billing GuidanceProvider Actions, Documentation, and Billing NotesDefinitions and Key TermsBackground

    Identify and bill the appropriate preventive medicine evaluation CPT when performing routine preventive visits. When a significant, separately identifiable medically necessary E/M is provided on the same date, report the E/M with modifier -25 and document medical necessity separate from the preventive components.

    • Initial (new patient) routine physical exam codes: 99385, 99386, 99387
    • Subsequent (established patient) periodic exam codes: 99395, 99396, 99397
    • If a separate problem‑focused E/M is performed, append modifier -25 and support with documentation of a distinct history, exam, and medical decision making
    Denial Risk

    Annual Visit Frequency Limit

    Florida Blue allows only one IPPE or AWV (initial or subsequent) per member per calendar year. Visits in excess of this limit will be denied (Reason: "Annual Wellness Visit Limit Exceeded"). The IPPE and the initial AWV are also limited to once per lifetime where noted.

    • One IPPE or AWV per member per calendar year across all providers
    • IPPE and initial AWV may be reported only once per lifetime
    Documentation Required

    Time‑based coding requirement

    When selecting an E/M code based on total time on the date of the encounter, document that total time and ensure it meets or exceeds 30 minutes to support the chosen code. When a separate, significant E/M is billed with a preventive service, append modifier -25 and document the distinct services.

    • Total time on date of encounter must be ≥ 30 minutes to use time for E/M selection
    • Document total time and contemporaneous activities that comprise that time
    • Use modifier -25 when billing a separate medically necessary E/M on the same date as IPPE/AWV and document distinct medical necessity
    Timing/limits
    Limited to new beneficiaries during the first 12 months of Medicare enrollment; reported only once per lifetime
    Related codesG0402 for IPPE; ECG screening codes G0403-G0405 when performed
    Preventive Medicine Services / Routine Physical Exam
    DefinitionComprehensive preventive medicine evaluation including age- and gender-appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and ordering of laboratory/diagnostic procedures
    ComponentsAge/gender-appropriate history; physical examination; counseling and anticipatory guidance; risk-factor interventions; ordering of labs/diagnostics
    Codes by patient statusInitial (new): CPT 99385-99387; Subsequent (established): CPT 99395-99397