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Level Requirement (all 3 must be at the billed level) Time (minutes) RVUs History Examination Medical decision-making HPI ROS PFSH Organ systems Diagnoses/complexity/risk Level 1 (N1) 99201 1–3 None None 1 Straightforward 10 0.48 Level 2 (N2) 99202 1–3 1 None 2–7 (no detail) Straightforward 20 0.93 Level 3 (N3) 99203 ≥ 4 2–9 1–2 2–7 (with detail) Low complexity 30 1.42 Level 4 (N4) 99204 ≥ 4 ≥ 10 3 ≥ 8 Moderate complexity 45 2.43 Level 5 (N5) 99205 ≥ 4 ≥ 10 3 ≥ 8 High complexity 60 3.17 HPI = history of present illness; PFSH = past medical, family, and social history; ROS = review of systems; RVU = Relative Value Unit
Level Requirement (at least 2 of the 3 must be at the billed level) Time (minutes) RVUs History Examination Medical decision-making HPI ROS PFSH Organ systems Diagnoses/complexity/risk Level 1 (E1) 99211 1–3 None None 1 Problem-focused 5 0.18 Level 2 (E2) 99212 1–3 1 None 1 Straightforward 10 0.48 Level 3 (E3) 99213 ≥ 4 1 None 2–7 Low complexity 15 0.97 Level 4 (E4) 99214 ≥ 4 2–9 1 2–7 (with detail) Moderate complexity 25 1.5 Level 5 (E5) 99215 ≥ 4 ≥ 10 2–3 ≥ 8 High complexity 40 2.11 HPI = history of present illness; ROS = review of systems; PFSH = past medical, family, and social history; RVU = Relative Value Unit
Service Wellness visit Standard office visit Cognitive assessment visit Cognitive assessment Yes No Yes Advance care planning Yes Yes No Depression screen Only if patient is established (G0439; not with G0402 or G0438) Yes Yes Smoking cessation Yes Yes Yes Alcohol screening Yes Yes Yes Alcohol counseling Yes Yes Yes STD counseling Yes Yes Yes Cardiovascular counseling Yes Yes Yes Weight counseling Yes Yes Yes G0439 = subsequent annual wellness visit code; G0402 = welcome to Medicare visit code; G0438 = initial annual wellness visit code; STD = sexually transmitted disease
Demographic data Self-assessment of health status Psychosocial risks Behavioral risks Activities of daily living Instrumental activities of daily living Updated personal and family history Substance use disorder assessment List of current health care providers and suppliers Documentation of weight, height, body mass index, and blood pressure Detection of cognitive impairment during visit (direct observation or third-party information helps) Depression screening Functional ability and level of safety (ability to successfully perform activities of daily living, fall risk assessment, hearing impairment screening, home safety assessment) Update all screenings recommended by US Preventive Services Task Force and vaccines recommended by US Centers for Disease Control and Prevention Action plan for any identified risks For more detailed information see: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf
Reason for visit
Chief complaint
Subjective narrative
Review of systems
“Please refer to patient-completed questionnaire (previsit template with checkboxes).”
Past medical history (diagnoses and dates)
Past surgical history
Family history
List of medications
Socioeconomic history
Substance use disorder assessment
Occupational history
Tobacco use
Recent hospitalizations
Objective
Vital signs, weight, height, body mass index
Physical examination
Vision and hearing evaluation
“Pertinent lab results and tests in the record were reviewed with the patient and a copy was provided to the patient as needed.”
Assessment of any cognitive impairment
General appearance
Mood and affect
Input from others
Notes and planDepression screening (PRIME MD-PHQ2)
Refresh note if PHQ-9 was completed Follow-up plan for depression
Functional ability
Does the patient exhibit a steady gait?
How long did it take the patient to get up and walk from a sitting position?
Is the patient self-reliant (can the patient do their own laundry, prepare meals, do household chores)?
Does the patient handle his or her own medications?
Does the patient handle his or her own money?
Is the patient’s home safe (eg, good lighting, handrails on stairs and bath)?
Did you notice or did patient express any hearing difficulties?
Did you notice or did patient express any vision difficulties?
Were distance and reading eye charts used?
Notes and plan
Advance care planning
Was patient offered the opportunity to discuss advance care planning?
If no, did you provide information on advance directives?
Notes and plan
Smoking cessation counseling
Electrocardiogram results
Required only in initial AWV
Vaccines
Screening recommendations
Assessments and planCognition-focused evaluation including a pertinent history and examination Medical decision-making of moderate or high complexity Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity Use of standardized instruments for staging of dementia (eg, Functional Assessment Staging Test [FAST], Clinical Dementia Rating [CDR]) Medication reconciliation and review for high-risk medications Evaluation for neuropsychiatric and behavioral symptoms, including depression, with use of standardized screening instrument(s) Evaluation of safety (eg, home), including motor vehicle operation Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks Development, updating or revision, or review of an advance care plan Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neurocognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support Typically, 50 minutes are spent face to face with the patient, family, or caregiver For detailed information see: https://www.alz.org/careplanning/downloads/cms-consensus.pdf Service CPT code RVUs Time (minutes) Recommended diagnosis Required interval Other requirements Cognitive assessment 99483 3.44 None None 180 days Cognitive Assessment Template
Not the same cognitive assessment described in the AWVAdvance care planning 99497
994981.5
1.4015–45
> 45None None Document discussion, outcomes, and signed forms Depression screening G0444 0.18 ≤ 15 713.31: Encounter for screening for depression 365 days Smoking cessation 99406
994070.24
0.503–10
> 10Severala Alcohol screening G0442 0.18 > 15 Any alcohol use code 365 days Patient must be having adverse effects from use Alcohol counseling G0443 0.45 > 15 Any alcohol use code 4 sessions per year Patient must have positive alcohol screen STD counseling G0445 0.45 > 30 Severalb 180 days Document education and skills provided Cardio-vascular counseling G0446 0.45 > 15 713.6: Screening for cardiovascular disease 365 days Must include intensive behavioral counseling to promote a healthy diet for adults with hyperlipidemia, hypertension, advancing age, and other known risk factors for cardio-vascular and diet-related chronic diseases
If a patient has a current diagnosis of hyperlipidemia and/or hypertension, the diagnosis codes for these diseases should be used instead of Z13.6; screening codes cannot be used if the patient already has a confirmed diagnosisWeight counseling G0447 0.45 > 15 BMI > 30.0 kg/m2 and weight-related diagnosis must be documented Month 1: weekly
Months 2–6: biweekly
Monthly thereafterGoal-oriented behavior ↵a For example, F17.210: Nicotine dependence, cigarettes, uncomplicated; F17.220: Nicotine dependence, chewing tobacco, uncomplicated; Z87.891: Personal history of nicotine dependence.
↵b For example, Z11.3: Encounter for screening for sexually transmitted infection; Z11.59: Encounter for screening for other viral disease; Z72.89: Other problems related to lifestyle; Z72.51: High-risk heterosexual behavior; Z72.52: High-risk homosexual behavior; Z72.53: High-risk bisexual behavior.
For detailed information see: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.
Advance care planning This is a time code. You must enter in the number of minutes spent on advance care planning. Example: “I spent ___ minutes with the patient on advance care planning.” You may also state “I have spent > 16 minutes on advance care planning.” Template suggestion: “I spent ___ minutes with the patient in counseling and discussion of goals of care, code status, and advance directives as detailed in the assessment and plan (excluding visit time and annual wellness visit time).” Depression screening This is a time code. You must enter in the number of minutes spent on depression screening Example: “ ___ minutes were spent on depression screening.” You must enter in the minutes on each patient. Template suggestion: ”I spent ___ minutes with the patient on screening and counseling about depression (excluding advance care planning and annual wellness visit time).”
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