Medicare Compliance & Reimbursement

The threat of COVID-19 has caused many Medicare patients to limit the number of places they go on a daily basis — and that includes visits to the doctor. In fact, some specialists may find that they’re performing more annual wellness visits (AWVs) than they did in the past, which can be tricky if you’re not used to doing them often.

If you want to keep the AWV reimbursement flowing into your practice, make sure you avoid some of the most common issues that Medicare payers see among these claims.

Context: The AWV is a yearly appointment for a provider to create or update a personalized prevention plan and perform a health risk assessment (HRA). During this yearly evaluation, the provider talks to the patient and creates or updates the preventive health plan.

Although these visits are often conducted by primary care providers, that isn’t always the case. More and more specialists are performing AWVs and offering preventive care, especially for vulnerable beneficiaries with chronic diseases who may feel more comfortable going to a provider they see every month versus one they see less frequently.

To ensure that your practice is documenting these visits properly, check out a few tips from CGS Medicare’s recent webinar, “CERT and Annual Wellness Visits,” where Part B experts outlined what you should — and shouldn’t — include in your documentation for these services.

Don’t Forget the AWV Timeline

When reporting AWVs, keep an eye on the calendar, said CGS’ Patsy Schwenk during the call. She reminded practices that Medicare covers the AWV for all beneficiaries who are no longer within 12 months of the eligibility date for their first Medicare Part B benefit period, and who have not had either an Initial Preventive Physical Exam (IPPE) or an AWV in the past 12 months. “If they’re still within their initial year of being on Medicare, they would not be eligible to receive the AWV,” she said.

Schwenk offered this example of a patient encounter: “Let’s say on January 1, 2020, the patient became Medicare eligible, so you know you can’t even offer an AWV until January 1, 2021,” she explained. “Assuming they did not take advantage of the IPPE, you can do the AWV any time starting January 1, 2021.”

Remember that Medicare only pays for one initial AWV (G0438, Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit) per beneficiary per lifetime, and then one subsequent AWV (G0439, … subsequent visit) per year thereafter.

In addition, don’t forget to link your AWV code to an appropriate ICD-10 code, said CGS’ Juan Lumpkin on the call. “You must report a diagnosis code when submitting a claim for the AWV,” he advised. Although a diagnosis specific to the AWV is not required, you can choose any diagnosis code consistent with the beneficiary’s exam.

Always Document Scheduled Screenings

One common error that the Part B payers see among AWV claims is when providers fail to document patient screening histories and schedules, said CGS’ Jolene Leonard in the webinar. During the AWV, the provider should establish a written screening schedule that shows the patient which preventive services they should have during the next five to 10 years. But this is often absent from records when they’re reviewed during Comprehensive Error Rate Testing (CERT) audits, Leonard acknowledged.

The screening history should show what the patient needs to have, when they need to have it, and when the most recent ones were.

For example, notes on when the most recent lab work, colonoscopy, and diabetic eye exams were completed are essential, along with the dates of when they had those services done in the past, which will help you plan for what they need to do in the future, and when. “Include that screening schedule if CERT asks for your AWV documentation,” Leonard noted.

Maintain Cognitive Function Assessment

Another common error, Leonard mentioned, was the absence of signed and dated documentation showing an assessment of the beneficiary’s cognitive function and establishment of or update to the medical/family history.

“At a minimum, you want to make sure that you document medical events of the parents, siblings, and children, that would include hereditary conditions or something that would put the beneficiary at an increased risk,” she said. “You want to also include the past medical and surgical history, including information about hospital stays, illnesses, operations, allergies, injuries, and treatments,” in addition to a complete medication and supplement history.

Always Maintain List of Providers, Suppliers

“Another error we’re seeing is documentation missing a list of current medical providers and suppliers who are regularly involved in providing medical care for the beneficiary,” Leonard said. “I’ve seen this problem regularly.”

Your physician should include documentation of the beneficiary’s providers and suppliers who are regularly providing medical care. “We’d like to see their name and designation,” she noted. “So if you’re a specialist, you’ll want to list their primary care doctor. If you’re a primary care provider, you’ll want to list any specialists they’re seeing.” The CERT reviewer will call in an error without this list, she said.

Be Sure to Record Functional Ability

Another common error involves a missing review of the individual’s functional ability and level of safety, based on direct observation of the individual or the use of appropriate screening questions, Leonard said.

“What is their risk of falling? Are they hearing impaired? How safe is their home?” she asked. “Make sure that’s included with documentation that you send to CERT,” she added.

Heads up: Targeted Probe and Educate (TPE) pre- and postpay claims reviews started back up in August. CGS updated its active list on Aug. 26 and put AWVs in a pending status for review — which is another great reason to ensure your claims are in check.