Part B Insider (Multispecialty) Coding Alert

If necessary, show patients the regulations in writing.

You pored over creating a simple-to-complete health risk assessment (HRA) form for patients to fill out during their annual wellness visits--and yet you still have a few stubborn patients who refuse to complete the form. Follow these five steps to ensure that you still collect for the visit.

Background: As part of the 2012 Physician Fee Schedule Final Rule, CMS requires that an HRA be included as part of every annual wellness visit (AWV). You should tailor your HRAs to the patients that you treat, taking into account all of CMS's requirements (see the Insider Vol. 12, number 40 for the list of mandatory topics, or email editor Torrey Kim for the article at torreyk@codinginstitute.com ).  

Despite the fact that the HRA is a relatively simple form that should take a patient 20 minutes or less to complete, some patients still refuse to participate. That's when you should consider your options if you want to collect for your AWV service, using the following five tips as guidance.

1. Send the patient a copy of the requirement. Patients who think they know more about Medicare rules than you do might be surprised to see in writing that the HRA is actually a required part of the AWV. Translation? If you don't have an HRA included, you may not get paid for the service.

Patients who fit into this category might benefit from seeing the rules in writing. Rather than sending them an entire Federal Register link, you might find it easier to show them CMS's document, "Interim Guidance for Health Risk Assessments and their Modes of Provision for Medicare Beneficiaries" from the CMS Web site. They'll not only see that the HRA is required, but will also find insight into what should be on the form.

If you do send them the link, consider highlighting the phrase, "The Patient Protection and Affordable Care Act of 2010 authorized an annual wellness visit (AWV) for Medicare beneficiaries. The Affordable Care Act specifies that a health risk assessment (HRA) be included as part of that visit." This document is available at www.cms.gov/coveragegeninfo/downloads/healthriskassessmentsCDCfinal.pdf

2. Assign a staff member to assist the patient in completing the HRA. According to the 2012 Physician Fee Schedule Final Rule, "CMS acknowledged

that the addition of the HRA might increase physician or other practitioner time...Furnishing a meaningful HRA to Medicare beneficiaries will require accommodation and that those beneficiaries may need assistance from physician office staff when completing the HRA."

To accommodate your staff members' time helping the patient complete the HRA, CMS raised the RVUs for G0438 (Annual wellness visit, including a personalized prevention plan of service, first visit) from 4.74 to 4.89, and raised the RVUs for G0439 (...subsequent visit) from 3.16 to 3.26 for 2012.

Time suggestion: CMS estimates that physician office staff time for helping beneficiaries complete an HRA should be 10 minutes for the first AWV and five minutes for subsequent AWVs.

3. Send it to the patient the day she makes her appointment. If you'd like to offer your patient extra time in completing the HRA, you can send the forms to her on the date that she schedules her visit with you. Then she will have ample time to work on the form at home or with family members prior to the visit.

4. If all else fails, have the physician go over it with the patient during the visit. According to CMS, the HRA "is intended to be a self-reported assessment completed before or during the annual wellness visit." Therefore, if it is performed during the visit with the patient's input, it appears that CMS will still consider it as "counting" toward the HRA requirement if the physician discusses all of the factors with the patient.

Plus, some of the criteria required in an HRA are already included in the physician's chart (such as demographic information), and the physician will review it with the patient anyway. Although it adds time to the visit, CMS did factor in additional payment for an AWV this year (see number 2 above) to account for the fact that practitioners may have to go over HRAs with patients.

5. Explain to the patient that without the HRA, you'll be forced to bill a preventive medicine visit--which is non-covered by Medicare. Without the HRA, you won't be able to complete all required aspects of the AWV, and you'll therefore have to turn to one of the preventive medicine codes (99381-99387). Because Medicare does not reimburse for these codes, you'll have to explain to the patient that she will be responsible for the charge. If the patient agrees to pay for the service, ask her to sign an advance beneficiary notice (ABN) with the expected amount of the charge, and keep a copy of the ABN on file. You'll append modifier GX (Notice of liability issued, voluntary under payer policy) to the preventive medicine code.