CMS Rescinds Coverage for Key Element in AWV

An amendment issued Jan. 10 by the Centers for Medicare & Medicaid Services (CMS) rescinds the addition and definition of “voluntary advance care planning,” as a specified element of the annual wellness visit (AWV).

The provision was initially added and finalized in the Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011 final rule, published in the Nov. 29, 2010 Federal Register.

CMS states in the amended regulation:

“It has since become apparent that we did not have an opportunity to consider prior to the issuance of the final rule the wide range of views on this subject held by a broad range of stakeholders (including members of Congress and those who were involved with this provision during the debate on the Affordable Care Act). Therefore, we are rescinding the provision of the final rule that includes voluntary advance care planning as a specified element of the annual wellness visits providing personalized prevention plan services, and returning to the policy that was proposed, which was limited to the elements specified in the Act.”

Under the Patient Protection and Affordable Care Act of 2010 (PPACA), Congress expanded Medicare Part B coverage to include an AWV providing personalized prevention plan services (PPPS), effective Jan. 1, 2011. The PPACA permits the U.S. Department of Health and Human Services (HHS), within which CMS resides, to add other elements to the AWV.

Prior to finalizing the 2011 Medicare Physician Fee Schedule (MPFS) final rule, CMS received a number of comments from physicians and other health care providers urging the federal agency to add voluntary advance care planning as an element to the definitions of both the first and subsequent AWVs. CMS agreed, stating: “We believe that this will help the physician to better align the personal prevention plan services with the patient’s personal priorities and goals.”

CMS went on to define “advance care planning” in the 2011 MPFS final rule to mean:

  1. An individual’s ability to prepare an advance directive in the case where an injury or illness causes the individual to be unable to make health care decisions.
  2. Whether  the physician is willing to follow the individual’s wishes as expressed in an advance directive.

This definition is based on that of the “end-of-life planning,” which is included as an element of the initial preventive physical examination (IPPE).

What Should Be Included in an AWV?

Effective Jan. 1, 2011, the first AWV providing personalized prevention plan services (reported with HCPCS Level II code G0438 Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit) include the following:

  • Establishment of an individual’s medical and family history.
  • Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.
  • Measurement of an individual’s height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine measurements as deemed appropriate, based on the individual’s medical and family history.
  • Detection of any cognitive impairment that the individual may have.
  • Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations.
  • Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations.
  • Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the U.S. Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
  • Establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
  • Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
  • Any other element(s) determined appropriate through the National Coverage Determination (NCD) process.

Subsequent AWVs providing personalized prevention plan services (reported with G0439 Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit) include the following:

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  • An update of the individual’s medical/family history.
  • An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing PPPS.
  • Measurement of an individual’s weight (or waist circumference), blood pressure (BP), and other routine measurements as deemed appropriate, based on the individual’s medical/family history.
  • Detection of any cognitive impairment that the individual may have.
  • An update to the written screening schedule for the individual as that schedule is defined in this section that was developed at the first AWV providing PPPS.
  • An update to the list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, as that list was developed at the first AWV providing PPPS.
  • Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs.
  • Any other element(s) determined by the NCD process.

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5 Responses to “CMS Rescinds Coverage for Key Element in AWV”

  1. Lori England says:

    I believe in certian circumstances the recently recinded rule covering AWV’s was good but given the uncertian political waters, CMS was wise to recind.

  2. Linda says:

    Boy! Just as I think I have it down, they go and change something. Thanks for keeping us in the know!

  3. Mark says:

    Does this have to do with those fearful “death panels” we heard talk about in congress? Maybe they should have considered the will of the people before they put something into law they either did not read or did not understand. I’m glad at least this provision has been pulled back.

  4. Lori says:

    Why would CMS put something into law without considering the wide range of views and also the Constitution (the pursuit of life, liberty, and happiness)?

    The issue of affordablility is a joke; our government uses taxpayer money to bail out banks and other businesses, and also just gives our money away to other contries to buy their “cooperation”…taxpayer money should go to taking care of US citizens

  5. Carolyn says:

    It is very interesting that the advance care planning provision allowed for variations of medical viewpoints, which seems very American. Yet it was rescinded because there was no pre-established consensus. What should that consensus be?

    I read the results of a poll recently that said 60 percent of the respondents did not want physicians to do “all that they possibly could” to prolong their lives if doing so severely impacted quality and death was going to occur no matter what. Forty percent wanted everything done, regardless of expense or the certainty of the final outcome.

    I fall in the majority and will simply ask my physicians to give me the necessary, honest guidance to eliminate interventions that will deplete me faster than the process of dying from whatever cause that awaits me. I prefer that the 40 percent who want no expense spared during their inevitable dying process to pay the tab from their own estates.

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