AWV and IPPE

kfrycpc

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This question is two fold and I need fresh opinions:

We have a long standing issue in our office. When a physician bills a preventive visit for a Medicare pt, it has to be either an IPPE or AWV.

1. When the Dr bills a regular preventive and bills a 99396....we cannot convert the code to an AWV code correct? Because there are elements of an AWV that aren't covered in a regular preventive correct?

And 2: if the latter is the case....the visit cannot be converted to a sick visit correct? We have been trying to explain all this but it's hard to find documentation on such. The problem begins with the scheduler scheduling a regular well visit and associated template and then the physician just follows it. Fixing the scheduling problem is what needs to be done...its at the crux of the issue.

TIA. :)
 

MLWILLINGHAM

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This question is two fold and I need fresh opinions:

We have a long standing issue in our office. When a physician bills a preventive visit for a Medicare pt, it has to be either an IPPE or AWV.

1. When the Dr bills a regular preventive and bills a 99396....we cannot convert the code to an AWV code correct? Because there are elements of an AWV that aren't covered in a regular preventive correct?

And 2: if the latter is the case....the visit cannot be converted to a sick visit correct? We have been trying to explain all this but it's hard to find documentation on such. The problem begins with the scheduler scheduling a regular well visit and associated template and then the physician just follows it. Fixing the scheduling problem is what needs to be done...its at the crux of the issue.

TIA. :)

1.) It's all in the documentation - when you show the provider the element requirements next to the note for the comprehensive they will see that it doesn't meet the criteria for the IPPE or AWV. There are documents out on the CMS' MedLearn Matters website called "the ABC's of the IPPE" and "the ABC's of the AWV" that cover the documentation requirements for both of these visits.

2.) This can become a public relations nightmare, most patients know that these Medicare screenings will have no deductible or co-insurance assessed; if you change the code because documentation doesn't support IPPE/AWV and bill an E/M the patient will receive an EOMB showing that there is a patient responsible balance and they might complain about abusive billing practices to their local Medicare representative. Not to mention if Medicare investigates and see that the documentation was for a preventive visit it won't support the E/M.
 

kfrycpc

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1.) It's all in the documentation - when you show the provider the element requirements next to the note for the comprehensive they will see that it doesn't meet the criteria for the IPPE or AWV. There are documents out on the CMS' MedLearn Matters website called "the ABC's of the IPPE" and "the ABC's of the AWV" that cover the documentation requirements for both of these visits.
QUOTE]

Thank you for replying. So if the preventive does not capture all the ABCs of the AWV or IPPE, does the charge have to be adjusted off? Is there another code that can be used in it's place?
 

thomas7331

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There is no substitute coding for a preventive/comprehensive physical if it does not meet the requirements of a IPPE or AWV, but these don't have to be adjusted off. Since they're statutorily excluded from Medicare coverage, they'll be denied as patient responsibility. Sometimes the patients' secondary insurance will cover these and if not, you are within your rights to bill the patient. But as the previous post mentioned, this can harm your relationship with the patients, so your practice will need to decide if the loss of revenue outweighs the potential impact to patient satisfaction.

The best practice is for the providers and staff to understand these coverage limitations and ensure that the patients know in advance when a routine physical won't be paid by Medicare so that they can make an informed decision as to whether or not they still want this service. In my experience, patients sometimes want this even when they know they may have to pay out of pocket for it. If this is an ongoing issue as you've said, your practice management really should create a policy and procedure for the office as to how the situation will be handled.
 
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