Pulmonology Coding Alert

Background: 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 annual 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. One registered nurse recently wrote to Pulmonology Coding Alert noting that her practice often sees patients for AWVs. “We have a few patients with serious lung issues that see our physician to treat those conditions, but the pulmonologist is basically the only physician they ever visit,” she wrote. “We are not in an area where it’s common to get preventive care. So it’s up to our practice to do AWVs or else patients may never get them.”

To ensure that your practice is documenting these visits properly, check out a few tips from CGS Medicare’s August 26th 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 said. “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 during the call. “You must report a diagnosis code when submitting a claim for the AWV,” he said. 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 during the call. 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) reviews, Leonard said.

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

Differentiate Annual Visit from AWV

Keep in mind that there’s a difference between an “annual visit” and an “annual wellness visit.” Practices cannot bill a preventive service to those payers do not accept the AWV codes since the service requirements are likely not met by a specialist who is responsible for managing the patient’s problems, nor do the commercial payers pay specialists for this service. Additionally, if the pulmonologist is not willing or able to meet every requirement of the AWV, the service cannot be billed.