Part B Insider (Multispecialty) Coding Alert

Use the government’s form as a springboard to creating your own tailored document.

It’s been four long years since CMS debuted codes G0438-G0439 for annual wellness visits (AWVs), but many practices were flummoxed about how to create the health risk assessment (HRA) that Medicare required patients to complete during the AWV. Fortunately, the Centers for Disease Control released a sample HRA that you can tailor to your practice’s specific needs.

What’s the HRA? An HRA is an evaluation tool used during an AWV that meets the minimum following requirements, CMS notes:

• Collects self-reported information about the beneficiary

• Can be administered independently by the patient or administered by a health professional before or during the AWV

• Is tailored to the patient, and takes into account any communication needs, such as limited English proficiency or literacy issues

• Takes 20 minutes or less to complete

• Addresses the following topics, at a minimum:

1. Demographic data, including age, gender, race, and ethnicity
2. Self-assessment of health status, frailty, and physical function
3. Psychosocial risks including depression/life satisfaction, stress, anger, loneliness/social isolation, pain, or fatigue
4. Behavioral risks including tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual practices, motor vehicle safety (seat belt use), and home safety
5. Activities of daily living, including dressing, feeding, toileting, grooming, physical ambulation (including balance/risk of falls), and bathing
6. Instrumental activities of daily living, including shopping, food preparation, using the phone, housekeeping, laundry, transportation, responsibility for own medications, and ability to handle finances.

Know the Scoop on the HRA

You’ll have the patient complete the HRA so the physician can base his questions and treatments to the issues that appear most relevant to the patient. That’s why the information in the HRA is so essential to your AWVs’ effectiveness. 

CMS asked practices to create their own HRAs based on their practice’s needs, and therefore didn’t release a sample at first. However, the CDC’s “A Framework for Patient-Centered Health Risk Assessments” document has a comprehensive sample that you can adapt for your practice. You should read through the CDC document, review the sample HRA, and determine which elements you’d like to adopt for your own form.

Resource: You can find the sample HRA form on page 43 of the document available at www.cdc.gov/policy/ohsc/HRA/FrameworkForHRA.pdf.

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