Medicare Compliance & Reimbursement

 Distinguish between “one-time-only” and “subsequent” for annual wellness visits.

When a patient presents for his annual wellness visit, make sure you’re using the right code. A recent update from one of the RACs suggests that it is on the lookout for initial AWV codes — which are once-in-a-lifetime codes — billed multiple times.

Problem: Performant Recovery, the Recovery Audit Contractor (RAC) for jurisdictions one and five, recently updated that it will be focusing on claims that abuse the one-time-only code HCPCS G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit). Review the audit update at https://www.dcsrac.com/IssuesUnderReview.aspx.

Details: When reporting an AWV, you should report G0438 beginning the second year the patient is eligible for Medicare Part B. You can only use this code for the first AWV per beneficiary per lifetime, a Medicare Learning Network (MLN) fact sheet on the subject notes.

And it is critical to understand that the first preventive exam is completely different than the AWV and subsequent AWVs. During the first year of the patient’s coverage, Medicare will only cover the Initial Preventive Physical Exam (IPPE), also known as the “Welcome to Medicare Preventive visit.” You report this initial visit within the first 12 months of enrollment with G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment).

Heed this: But remember, you cannot report G0402 if your physician conducts an initial preventive exam after the patient’s first 12 months following Medicare enrollment. If 12 months have already passed, then you should consider reporting the visit with G0438 or G0439.

Medicare only covers an AWV if the beneficiary has not gotten either an IPPE or another AWV within the past 12 months — that is, at least 11 months have passed following the month in which the IPPE or the last AWV was performed, the MLN guidance suggests.

What Determines Whether a Patient is “New” or “Established” for This Service?

“A new patient is defined as one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years,” says attorney Michael D. Bossenbroek, Esq. of Wachler & Associates, P.C. in Royal Oak, Mich.

Here’s where concise recordkeeping makes a difference. “Prospectively, the physician should be confirming if this patient has received professional services from him or another physician of the same specialty in his group practice in the past three years,” Bossenbroek adds. “Hopefully, physicians have the capability to track this information. Properly categorizing these patients will likely go a long way towards reducing exposure to a RAC audit of this issue.”

Remember a Different Provider Requires a Different Code

If you see a patient for the initial visit, using G0438, and then the patient sees a different physician for the next annual wellness visit, that second physician should report the AWV with a subsequent visit code G0439 (Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit), despite having never seen the patient before.

Here’s why: Like with HCPCS code G0402, which is paid only once for a particular patient when a physician performs the IPPE (within the first 12 months of enrollment), G0438 is also paid only once per beneficiary, whether the patient sees the same or any other physician in the second year for an AWV. Once reimbursement for G0438 has been claimed, for subsequent years, AWVs will have to be reported with G0439, irrespective of whether the patient is visiting the same physician or a new physician.

RAC reminder: “Because they are paid on a contingency-fee basis, RACs are highly motivated to find that claims were billed improperly,” notes Michigan law firm Wachler & Associates in its online analysis. “The RAC’s contingency fee is based upon the amount collected from and/or returned to Medicare providers or suppliers resulting from improper payments.”

Unfortunately, RACs often “focus on the identification of overpayments rather than underpayments,” mentions the Wachler & Associates analysis. This reasons with why Performant Recovery has added G0438 to its audit junket as it is a higher paying code than both G0439 and G0402. Read the Wachler & Associates analysis at https://www.wachler.com/racs.html.

Tip: Medicare has links and guidance to help you identify which service the patient should receive and what code to append. “You have different options for accessing AWV eligibility information depending on the jurisdiction where you practice,” Bossenbroek says. “You may be able to access the information through the HIPAA Eligibility Transaction System (HETS) or through the provider call center Interactive Voice Responses (IVRs). He adds, “CMS suggests providers check with their Medicare Administrative Contractor (MAC) to see what options are available to check beneficiary eligibility. For MAC contact information, visit http://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/Medicare-FFS-Compliance-Programs/Review-Contractor-DirectoryInteractive-Map on the CMS website.”

What If You Do Get a Letter from Your RAC on Your AWV Claims?

An audit letter may be an unwelcome sight, but it should never be a cause for uncertainty. The letter should spell out exactly 1) which records the payer needs, and 2) the deadline by which you should have those records ready to be audited.

It’s your responsibility to read all audit letters thoroughly and to respond as soon as possible. This is especially vital when the auditor is looking for a reimbursement of over-coded or over-billed money. “If you don’t respond by the deadline, you’re going to be considered to agree with their charge, and you’ll owe the money back,” advises Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

Respond with evidence: The letter can also offer you a golden opportunity to avoid the audit entirely. You can appeal the claim, provide all the supporting documents to make your case, and make an in-person visit from the auditors unnecessary. The better you build your case through explanations and evidence, the less time you’ll spend across the table from scary auditors. This process can be a very effective way of dealing with audits by RACs. “They base their audits entirely on computer modeling,” Cobuzzi explains. “So don’t just automatically accept what they say!”

Resource: See the AWV fact sheet at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf.