Keep Annual Wellness Visit Coding in Check 

Keep Annual Wellness Visit Coding in Check 

Claims payment for this Medicare benefit is all in the timing.

Medicare established two codes for billing and reimbursement of an annual wellness visit (AWV), effective for services provided on or after January 1, 2011. There are two types of AWVs: an initial visit and a subsequent visit.

The initial AWV is a once-in-a-lifetime benefit, allowed after the first 12 months of Medicare enrollment have elapsed and at least 11 full calendar months have passed since the patient’s initial preventive physical exam (IPPE). According to the Centers for Medicare & Medicaid Services’ (CMS) frequently asked questions (FAQs) regarding AWV and IPPEs, the patient does not have to wait 365 days after the IPPE before qualifying for the initial AWV.

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If the patient misses the IPPE, he or she is still eligible for AWV benefits after the initial 12 months of Medicare Part B enrollment. The beneficiary becomes eligible for a subsequent AWV after 11 full months have passed since the initial AWV.

Tip: Medicare managed plans also reimburse for AWVs.

Components of an AWV

The AWV includes the establishment of, or update to, the patient’s medical history, family history, height, weight with body mass index (BMI), blood pressure. The goals are health promotion and disease detection. Clinical labs are not a part of the AWV; however, a provider may order these tests, when appropriate.

A common misconception for both providers and beneficiaries is that an AWV is a “routine physical.” An AWV is not an annual routine physical; Medicare does not reimburse for routine physicals. The focus of the AWV is preventive health.

Initial AWV

The initial visit, reported with HCPCS Level II code G0438 Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit, includes:

  • Review of a health risk assessment (HRA);
  • Establishment of an individual’s medical and family history, including a list of medications and supplements;
  • Establishment of a list of current providers and suppliers involved in the patient’s medical care;
  • Measurement of height, weight, BMI, and blood pressure;
  • Detection of cognitive impairment;
  • Review of the patient’s risk factors for depression;
  • Review of the patient’s functional ability and safety;
  • A written screening checklist for the next five to 10 years and a list of risk factors with intervention recommendations;
  • Health advice and referrals, as appropriate for the patient;
  • Voluntary advance care planning upon agreement with the individual; and
  • Any additional elements pertinent to the patient based on their history, HRA, age, and lifestyle.

Subsequent AWV

The subsequent visit, reported with G0439 Annual wellness visit; includes a personalized prevention plan of service (pps), subsequent, includes:

  • Review of an updated HRA;
  • Updating the patient’s medical and family history, including medications and supplements;
  • Updating the list of current providers and suppliers involved in the patient’s medical care;
  • Measurement of weight and blood pressure;
  • Detection of cognitive impairment;
  • Updating the written screening checklist and a list of risk factors with intervention recommendations;
  • Health advice and referrals, as appropriate for the patient;
  • Voluntary advance care planning upon agreement with the individual; and
  • Any additional elements pertinent to the patient based on their history, HRA, age, and lifestyle.

Common Questions

What is an HRA? 

CMS defines an HRA as an evaluation tool administered independently, or by a health professional, to collect self-reported information taking no more than 20 minutes to complete. It can be administered prior to or during the visit, and it must take into account those with literacy deficits or limited English proficiency. It should address: demographic data, health status, physical functioning, psychosocial risk, behavioral risk, activities of daily living, and instrumental activities of daily living.

What is detection of cognitive impairment? 

CMS says it’s assessing an individual’s cognitive function by direct observation, with consideration of information obtained through patient reports and concerns raised by family members, friends, caretakers, or others.

What is functional ability and level of safety? 

CMS explains that this will include, at a minimum, assessment of hearing impairment, ability to perform successfully activities of daily living, fall risk, and home safety. This can be performed by direct observation or with the use of a screening questionnaire.

What diagnosis code do I submit on the claim?

CMS does not require a specific diagnosis code on the AWV or IPPE claim, and advises the provider to use any appropriate diagnosis code.

Denials

If a provider bills for an initial AWV for a patient who has already had an initial AWV, Medicare will deny the claim with Claim Adjustment Reason Code (CARC) 149 Lifetime benefit maximum has been reached for the service/benefit category and Remittance Advice Remarks Code (RARC) N117 This service is paid only once in a patient’s lifetime.

Tip: If you are not sure whether the patient has received an initial AWV by another provider, you will need to contact the MAC for the jurisdiction in which the patient would have had the service performed to verify the patient’s eligibility.

If an initial AWV is provided within 11 months of the IPPE, or a subsequent visit is provided within 11 months of the initial AWV, Medicare will deny the claim with CARC 119 Benefit maximum for this time period or occurrence has been reached and RARC N130 Consult plan benefit documents/guidelines for information about restrictions for this service.

If an AWV is billed within the first 12 months of a beneficiary’s Medicare Part B coverage, it will be denied with CARC 26 Expenses incurred prior to coverage and RARC N130.

Additional Services

Medicare allows additional services to be provided and billed on the same date as the AWV; however, you must follow applicable coding guidelines. For example, if the physician provides a medically necessary evaluation and management (E/M) visit on the same date as the AWV, and documentation supports a significant, separately identifiable service, you may separately report the appropriate E/M code with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended.

Remember: An element that is part of the AWV cannot be used to determine the level of an E/M exam.

Vaccinations and injections may be given on the same date as an AWV, as can orders for lab work, electrocardiograms, or other testing.

For example, a patient is seen for her subsequent AWV. Her physician performs and documents all the necessary components. While updating her screening and risk factors, the provider notices the patient has not had a flu vaccination during the current flu season. The patient agrees to have the vaccination. The nurse enters the room and administers the Fluzone vaccination. Correct coding for this scenario is G0439, G0008 Administration of influenza virus vaccine, and Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluzone).

Resources

Take advantage of the free resources CMS publishes on its website:

The ABC’s of the Annual Wellness Visit:

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf

FAQs IPPE and AWV:

www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/IPPE-AWV-FAQs.pdf

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/IPPE_AWVQuestions.pdf

Angela Clements, CPC, CEMC, COSC, CCS, is the physician coding auditor/educator consultant at Medkoder. She has over 17 years of experience in the healthcare industry. Clements serves on the AAPC National Advisory Board as the member relations officer, and in the past served as Region 5 representative from 2013-2015. She is president of the Covington, La., local chapter. Clements has extensive experience in multi-specialty coding, documentation, and auditing. She’s also a frequent speaker at local medical managers’ meetings and local chapters in her region.

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