Medicare Compliance & Reimbursement

All 3 RACs spotlight this perennial Medicare problem.

Annual wellness visits (AWVs) and initial preventive physical exams (IPPEs) are a continual source of confusion for both patients and providers. Even after questions are asked and files are checked, mistakes are often made — mostly due to a combination of lapsed or inaccurate medical records and confusion over Medicare’s policies. That’s why AWVs and IPPEs are back on the recovery audit contractors’ (RACs’) radar.

Background: It’s easy to mix up Medicare’s coverage rules for IPPEs and AWVs — and apparently many providers are doing just that. Three of the RACs recently identified AWVs billed within 12 months of an IPPE as an audit focus as well as issues with providers incorrectly billing IPPEs more than once to Medicare. This means that auditors will be focusing on claims reported this way and contacting practices that billed these services incorrectly.

Details: This January Performant Recovery, Cotiviti, and HMS Federal Solutions all announced that they will target claims violating the Centers for Medicare & Medicaid Services’ (CMS) guidelines for these common services. The three RACs released identical descriptions, outlining what they’re looking in to.

HCPCS code G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment) claims “billed more than once in a lifetime, or after the initial 12 months or 12 months after the effective date of the beneficiary’s first Part B coverage period will be denied,” says Cotiviti.

In addition, “claims for HCPCS code G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit) billed more than once in a lifetime will be denied,” too, Performant explains. And HCPCS code G0439 (Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit) claims “billed more than once within 12 months of G0438 or G0439 will be denied” as well, HMS says.

Know the Code Distinctions to Avoid the Problem

You might think coding the “Welcome to Medicare” IPPE is fairly basic, or that keeping AWV claims in check is straightforward, but it’s not. In fact, the RACs point to incorrect coding as the primary reason for the inclusion of AWVs and IPPEs on their approved audit lists.

During the first year of the patient’s coverage, Medicare will cover only the IPPE — informally called the “Welcome to Medicare” visit. You report this initial visit within the first 12 months of enrollment using HCPCS code G0402.

It’s important that you understand that the first preventive exam is completely different than the AWV and subsequent AWVs. If the patient has been enrolled in Medicare for more than 12 months before their first IPPE, this changes the code used. For these encounters, you might report a code such as G0438 or G0439 rather than G0402.

Tip: “When calculating AWV eligibility, a full 11 months must pass following the month in which the last AWV was performed,” advises Part B Medicare Administrative Contractor (MAC) Palmetto GBA in online guidance.

For example, if a beneficiary receives an AWV on Jan. 25, 2020, he will be eligible for his next AWV on the first day of that month in the next calendar year. In this scenario, that would be Jan. 1, 2021. “A full 365 days is not required between AWVs,” Palmetto says.

Check your individual Medicare carrier’s policy if you’re unsure how to code for these services. Additionally, you will want to make certain all requirements of the code match the documentation of the service.

Non-Medicare patients: Since the “Welcome to Medicare” exam is a CMS benefit, you must be sure that the patient is a Medicare beneficiary — or has insurance that follows Medicare’s billing rules — before choosing G0402 for an IPPE. If you’re unsure how to code an IPPE for a private payer, check with the payer before filing the claim. Also, it’s important to note that there are services the physician might provide during an IPPE that you could also code separately, depending on the payer’s specific policy.

Resource: Review Medicare’s AWV guidance at  www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf.