Medicare lays out clear guidelines for Annual Wellness Visits (AWV), including Personalized Prevention Plan Services (PPPS). There are a number of specific requirements of these visits in order to be eligible for reimbursement. Providers will develop a personalized prevention plan after reviewing a patient’s health risk assessment, conducting a cognitive assessment, obtaining routine measurements, reviewing family history and more.[1]
Who is eligible?
An AWV is available to beneficiaries who have had Medicare Part B coverage for longer than 12 months AND who have NOT received an AWV or an Initial Preventive Physical Examination (IPPE) in the last year.
How is it billed?
There are two codes used:
G0438 – Initial AWV
G0439 – Subsequent AWV
What to look for?
Auditors and investigators should:
• review claims data to ensure that AWV is not billed within the first 12 months of coverage
• review claims data to ensure that only one AWV is billed within a 12-month period
• ensure providers did not bill for both G0438 and G0439 within a 12-month period
• review for outliers
• review for potential unbundling of evaluation and management visits
• review medical records to confirm key elements of the visit are documented per Medicare guidelines.
Medicare guidelines include, but are not limited to[2]:
• a health Risk Assessment
• a review of Medical History
• a medical exam including measurement of a beneficiary’s height, weight, BMI and any other measurements deemed appropriate
• cognitive impairment detection
• review of risk factors for depression
• review of functional ability
• written screening schedule
If you are using the HCFSPlatform™, HCFS has you covered. Our 1750+ library of alerts used in combination with our artificial intelligence detects known and unknown schemes. HCFS captures known schemes AWVs with both our AI and with alerts such as:
[2230-20] – SERVICES NOT RENDERED/MISREPRESENTATION OF SERVICE, MODIFIER 25
[2405-02] – UNBUNDLING, SUBSEQUENT ANNUAL WELLNESS VISIT BILLED WITH ESTABLISHED PATIENT E/M CODES
HCFS worked with one of our clients recently on this issue resulting in hundreds of thousands of dollars in overpayments for just one provider. Approximately 70% of the services did not meet the CMS guidelines.
REFERENCES:
[1] https://www.medicare.gov/coverage/yearly-wellness-visits
[2] https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R134BP.pdf
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