Pulmonology Coding Alert

Ensure that you aren't exceeding the frequency guidelines with these services.

It can be easy to mix up the annual wellness visit (AWV) and an initial preventive physical exam (IPPE) - and apparently many providers are doing just that. Three of the recovery audit contractors (RACs) recently identified AWVs billed within 12 months of IPPE as an audit focus, which means that auditors will be seeking claims reported this way and contacting practices that billed these services incorrectly.

Problem: Performant Recovery, Cotiviti, and HMS all announced in January that they would be homing in on claims that violated CMS guidelines for these services. "The Annual Wellness Visit is not payable if an Initial Preventative Physical Examination has been paid within the previous 12 months," Performant said on its website. "Affected Codes: G0438, G0439, G0402."

Details:  When reporting an AWV, you should report G0438 (Annual wellness visit; includes a personalized prevention plan of service [PPPS], initial visit) 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 IPPE, also known as the "Welcome to Medicare Preventive visit." You report this initial visit within the first 12 months of enrollment using G0402 (Initial preventive physical examination; face-to-face visit, services limited to newbeneficiary during the first 12 months of Medicareenrollment).

Heed this: Remember, Medicare only covers an AWV if the beneficiary has not gotten either an IPPE or another AWV within the past 12 months.

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 extreme stress. 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 because the auditor is looking for 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 the contractor will be notified to recover the money, advises Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.