Auditing Preventive Services in 5 Steps

Article Reference Code: NAMAS.10.03.2025

Auditing Preventive Services in 5 Steps

Written by: Anna M. McGregor

Preventive healthcare plays a crucial role in maintaining patient well-being, reducing long-term healthcare costs, and identifying risks before they escalate into acute illnesses. Within the U.S. healthcare system, preventive services are emphasized through programs such as the Medicare Annual Wellness Visit (AWV) and commercial insurance preventive care packages, which are aligned with the Affordable Care Act (ACA). For providers and healthcare organizations, these visits present opportunities to address immunizations, chronic disease screenings, and health risk assessments, including through telehealth modalities. However, consistent and compliant documentation requires auditing processes that ensure both quality of care and regulatory adherence. 

Defining Preventive Services 

• Medicare Beneficiaries:
  For Medicare patients, preventive services are defined as evidence-based healthcare interventions provided without cost-sharing when furnished by a qualified provider. These include screenings (e.g., cardiovascular disease, diabetes, depression), immunizations, counseling, and the AWV. Medicare distinguishes AWVs from a “routine physical exam”; AWVs are structured encounters designed to update a health risk assessment and create a personalized prevention plan.[1]
• Commercially Insured Patients:
  For non-Medicare patients, preventive services are guided by the ACA’s requirement that most health plans cover services, rated A or B by the U.S. Preventive Services Task Force, without patient cost-sharing. This includes cancer screenings, childhood and adult immunizations, and counseling for chronic conditions.[2]
• Importance of Preventive Services:
  By integrating preventive care into routine practice, providers can improve population health, reduce emergency department utilization, and capture risk-adjustment factors essential for accurate reimbursement in value-based care arrangements. 

Medicare CPT/HCPCS Codes for AWVs 

Medicare uses Healthcare Common Procedure Coding System (HCPCS) codes to describe AWVs:[3]

• G0402 – Initial Preventive Physical Examination (IPPE, “Welcome to Medicare” visit, within 12 months of Part B enrollment).
• G0438 – Initial Annual Wellness Visit (first AWV).
• G0439 – Subsequent Annual Wellness Visit (each year after the initial).

These codes require documentation of a health risk assessment, medication reconciliation, family history, a list of current providers, and creation or update of a personalized prevention plan. 

AMA CPT Codes for Preventive Services 

The American Medical Association (AMA) CPT manual uses 99381-99397 to describe comprehensive preventive medicine services based on patient age and new vs. established status.[5] These codes, unlike Medicare’s AWVs, encompass a broader preventive examination, including physical exams, counseling, and anticipatory guidance.

While Medicare will not reimburse CPT preventive visit codes for AWVs, commercial payers generally do. Providers must clearly distinguish whether the encounter is billed under Medicare’s AWV HCPCS codes or the AMA CPT preventive visit codes to avoid denials or compliance risk. 

Opportunities for Preventive Services During AWVs

1. Annual Immunizations:
   • Influenza, pneumococcal, shingles, and COVID-19 vaccines can be reviewed and administered during AWVs. These services can be separately reported using CPT vaccine administration codes (90460-90474) with the appropriate vaccine product codes.[6]
   • Capturing immunization status during AWVs strengthens quality measure performance (e.g., HEDIS).
2. Chronic Condition Screening:
   • Screenings for hypertension, diabetes, obesity, depression, and substance use can be integrated into the AWV template.[7]
   • Positive results trigger further evaluation, coding specificity for risk adjustment (e.g., hierarchical condition categories, HCCs), and follow-up plans.
3. Telehealth Expansion:
   • During the COVID-19 Public Health Emergency and beyond, CMS has allowed AWVs to be furnished via telehealth.[8]
   • Telehealth AWVs enable outreach to patients with transportation barriers, rural populations, or those reluctant to attend in-person visits.
   • Hybrid models (telehealth AWV plus in-person immunization/nurse visit) optimize patient access while meeting requirements. 

The Five-Step Auditing Process for Preventive Services 

A systematic audit process helps organizations ensure accurate billing, capture of preventive opportunities, and compliance with payer regulations. The following five-step process provides a framework:

1. Encounter Selection and Risk Stratification 

• Identify a representative sample of AWVs and preventive visits across providers, payers, and service modalities (in-person vs. telehealth).   
• Confirm which HCPCS is appropriate for the Medicare patient, to avoid possible rejections.  Know Medicare’s guidelines for AWVs. [4]
• Stratify encounters by initial vs. subsequent AWVs, preventive CPT codes, and whether immunizations or screenings were included.

2. Documentation and Element Review 

• Compare documentation against required elements:
  • For Medicare AWVs, confirm completion of health risk assessment, review of medications, updated provider list, functional and cognitive assessment, and prevention plan.[3]
  • For CPT preventive visits, confirm inclusion of age- and gender-appropriate history, physical exam, and counseling.[5]
• Validate whether additional screenings (e.g., depression, fall risk) were administered and properly documented.

3. Code Assignment and Compliance Validation:

• Verify that the correct HCPCS or CPT code was used, avoiding overlap between Medicare AWVs and CPT preventive visits.
• Ensure vaccine and screening services were billed separately with appropriate modifiers (e.g., 25 modifier when a problem-oriented E/M encounter was performed at the same visit; ensure components of an E/M encounter are met and no overlap of discussion is used in determining level of service).
• Review for potential upcoding, undercoding, or duplicate billing.

4. Preventive Opportunity Capture:

• Audit whether patients received recommended immunizations or screenings, and whether referrals were made when indicated.
• Measure preventive service capture rates across providers to identify care gaps.
• Review whether risk-adjustable chronic conditions identified during AWVs were coded with specificity.

5. Feedback, Education, and Continuous Monitoring:

• Provide individualized provider feedback, with examples of compliant and non-compliant documentation.
• Offer coder and provider education on AWV requirements, CPT vs. HCPCS coding differences, and telehealth documentation rules.
• Implement ongoing monitoring dashboards to track AWV utilization, preventive service capture, and audit outcomes over time. 

Conclusion 

Annual Wellness Visits represent a cornerstone of Medicare’s preventive strategy, while CPT preventive visits fulfill a similar role for commercially insured patients. These encounters create opportunities not only to improve individual patient outcomes but also to advance population health goals through immunization, chronic condition screening, and the expansion of telehealth services. A structured five-step auditing process—focusing on encounter selection, documentation review, code compliance, preventive opportunity capture, and provider feedback—ensures that organizations maximize both compliance and patient care benefits. Ultimately, preventive services reduce long-term costs, support value-based care, and reinforce the commitment to proactive, patient-centered healthcare. 

 

References 

[1] Centers for Medicare & Medicaid Services (CMS). Medicare Preventive Services. https://www.cms.gov/medicare/coverage/preventive-services-coverage  

[2] U.S. Preventive Services Task Force. A and B Recommendations. https://www.uspreventiveservicestaskforce.org  

[3] MLN Educational Tool-Medicare Preventive Services (CMS). https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#AWV  

[4] MLN6775421-Medicare Wellness Visits (CMS).  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html  

[5] American Medical Association (AMA). CPT 2025 Professional Edition. 

[6] AMA CPT. Vaccine Administration Codes 90460-90474. 

[7] CMS Quality Measures. Chronic Condition Screening. https://qpp.cms.gov  

[8] CMS Telehealth Services. https://www.cms.gov/medicare/medicare-general-information/telehealth 

 

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Anna M. McGregor, CPC, CPCO, CPMA, CEMC, CEMA, CPA-RA 

Anna M. McGregor is an experienced leader in administration and directorship with a strong background in higher education. She brings proven expertise in account reconciliation, compliance auditing, and federal grants management, alongside specialized knowledge in medical billing and coding, with a focus on Evaluation and Management (E/M) coding and trauma services.

Her professional skill set also includes public speaking and non-profit fund development, reflecting her ability to engage diverse audiences and support organizational growth. Anna is a dedicated healthcare services professional who continues to strengthen her expertise through additional certifications from NAMAS and AAPC.