Part B Insider (Multispecialty) Coding Alert

Published on Mon Oct 04, 2010 PDF

In the absence of a CMS-issued health risk assessment (HRA) form for practices to complete during annual wellness visits, CMS has issued the following definition of an HRA to help guide practices creating their own tools.

An HRA is an evaluation tool that meets the minimum following requirements, CMS indicates in its 2012 Physician Fee Schedule Final Rule:

Collects self-reported information about the beneficiary

Can be administered independently by the patient or administered by a health professional before or during the AWV

Is tailored to the patient, and takes into account any communication needs, such as limited English proficiency or literacy issues

Takes 20 minutes or less to complete

Addresses the following topics, at a minimum:

• Demographic data, including age, gender, race, and ethnicity
• Self-assessment of health status, frailty, and physical function
• Psychosocial risks including depression/life satisfaction, stress, anger, loneliness/social isolation, pain, or fatigue
• Behavioral risks including tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual practices, motor vehicle safety (seat belt use), and home safety
• Activities of daily living, including dressing, feeding, toileting, grooming, physical ambulation (including balance/risk of falls), and bathing
• Instrumental activities of daily living, including shopping, food preparation, using the phone, housekeeping, laundry, transportation, responsibility for own medications, and ability to handle finances.