How CCM and AWVs Work in Harmony to Strengthen Practice Performance
In today’s value-based care environment, practices need to balance high-quality, preventive care with sustainable financial performance. Two of Medicare’s most impactful programs—Annual Wellness Visits (AWVs) and Chronic Care Management (CCM)—are often implemented separately. But when strategically integrated, they can create a powerful care delivery and revenue cycle engine.
Annual Wellness Visits: The Preventive Care Foundation
AWVs give practices a structured opportunity to address preventive health needs. They include:
Comprehensive health and risk assessments
Identification of chronic conditions and care gaps
Creation or update of personalized prevention plans
Patient engagement around screenings and lifestyle improvements
Reimbursement Details:
Initial AWV (CPT G0438): ~$170–$180
Subsequent AWVs (CPT G0439): ~$120–$130
For practices, AWVs not only enhance patient care but also create opportunities to identify candidates for additional care management services like CCM.
Chronic Care Management: Extending the Touchpoints
CCM ensures that patients with two or more chronic conditions receive ongoing support between visits. This includes:
Monthly non-face-to-face check-ins by care coordinators
Medication reconciliation and adherence monitoring
Coordination across specialists and primary care
Progress tracking against the AWV-derived prevention plan
Reimbursement Details (per patient, per month):
CPT 99490: ~$62 for 20 minutes of clinical staff time
CPT 99439: ~$47 for each additional 20 minutes
CPT 99491: ~$84 for 30 minutes of physician/QHP time
CPT 99437: ~$121 for each additional 30 minutes
This recurring reimbursement creates predictable revenue while supporting better patient outcomes.
Why CCM and AWVs Are Stronger Together
When practices align AWVs and CCM, they unlock significant clinical and operational value:
Streamlined Identification – AWVs naturally flag CCM-eligible patients.
Care Plan Continuity – AWV prevention plans evolve into CCM care roadmaps.
Improved Quality Scores – CCM helps practices close care gaps identified at the AWV.
Revenue Optimization – Together, AWVs and CCM can generate over $1,500 per patient annually.
Note: These figures don’t include additional CCM billing opportunities (99439, 99491, 99437), which can further increase revenue if patients require more extensive care management.
The Bottom Line for Practices
AWVs and CCM are not isolated programs—they are complementary services that fuel each other. By connecting the annual preventive snapshot (AWVs) with monthly chronic care support (CCM), practices can strengthen patient outcomes, optimize revenue, and improve operational efficiency.
For practices in the Medicare space, integrating AWVs and CCM isn’t just good clinical practice—it’s good business.
