Health Information Compliance Alert

Reader Question:

Patient Wants Physical But Refuses AWV? Document Everything

Published on Mon Jan 09, 2012

Question: Several of our patients have presented to our office for a complete preventive physical. They tell us they've heard that the annual wellness visit (AWV) is not comprehensive and therefore they don't want it, so we document this fact and charge an established patient preventive medicine exam (such as 99397). Then when the patients get the denials from Medicare, they call the MAC to complain and the MAC tells them "your doctor didn't code it correctly to get it paid." The patients then call us and complain that we miscoded their claims. What is the solution to this problem?

Answer: First and foremost, you must ensure that you've communicated to the patients that they are requesting a service that is non-covered by Medicare, said Marc Hartstein, deputy director of the Hospital and Ambulatory Policy Group at CMS, during the CPT® 2012 Annual Symposium in Chicago on Nov. 16.

Explain to the patient the difference between the AWV (which is rendered at no charge to the patient) and a preventive visit (which the patient will have to pay for in full). If the patient still refuses the AWV and requests the preventive exam instead, document these details in the patient's record.

Although an advance beneficiary notice (ABN) is not required since preventive visits are statutorily non-covered by Medicare Part B, it might be in your best interest to have such patients sign an ABN anyway. That will serve as further proof that the patients knew that they would have to pay for the visits on their own.

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