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Billing and coding for the medicare annual wellness visits.

Services provided during all three types of AWVs involve establishing and/or updating patient records with essential vital signs, personal and family health status and history, medications and indications.  Physicians can help patients get ready for their AWV by encouraging them to come prepared with the following information:

• Medical Records, including immunization records
• Family health history with as much detail as possible
• Full list of current medications--including calcium, vitamins and over-the-counter products–and dosage and frequency for each
• Full list of current providers and suppliers involved in providing care

  Three Visits With Three Sets Of Requirements

  1.)    G0402 – Initial preventive physical examination, face to face with patient, this service is for new Medicare beneficiaries and must be performed within the first 12-months of Medicare Enrollment. This is not a physical exam, even though the physician does measure and record basic vitals, but the patient is also eligible for an EKG screening (electrocardiograph--G0403-G0405) and aortic aneurism ultrasound (AAU) if they meet certain guidelines for these services.  Often referred to as the “Welcome to Medicare Physical,” this benefit is only payable once during an enrollee’s lifetime.  If a patient does not take advantage of the Welcome To Medicare visit within their first year of Medicare enrollment, they lose the Welcome Visit benefit, and it can never be recovered.

For more details on EKG and AAU screenings , please visit the CMS website.  

2.)    G0438 – Annual Wellness visit: Initial visit, includes a personalized prevention plan of care (PPPS).  Once a patient has had the Welcome to Medicare Visit, 11 full months must pass before the patient is eligible for the Annual Wellness Visit, Initial Visit.  This visit can be preformed any time in the patient’s life, but can only be performed once .  If a patient did not have the “Welcome to Medicare” visit within that first year of Medicare enrollment, they are still eligible for the Initial Annual Wellness Visit at any point in their life.

At the Initial Annual Wellness Visit, the health care provider will perform all of the key components of the visit, and record and discuss findings with the patient.  Together, the provider and patient will devise a wellness plan and screening schedule intended to aid in maintaining or improving the health of the patient.  The key elements include:

• Establishment of the patient’s medical/family history
• Measurement of the patient’s height, weight, BMI (body mass index), blood pressure, and other routine measurements as deemed appropriate, based on patient’s medical and family history
• List of current providers and suppliers (diabetic supplies, etc) that are regularly providing care
• Detection of any cognitive impairments the patient may have
• Review of a patient’s potential risk factors for depression
• Review of the patient’s functional ability and level of safety, based on direct observation of the patient
• Establishment of written screening schedule for the patient, such as a checklist for the next 5-10 years
• Establishment of a list of risk factors and conditions against which primary, secondary, or tertiary interventions are recommended or underway for the patient, including any mental health conditions or any such risk factors or conditions that have been indentified through an initial preventive physical exam (IPPE), and a list of treatment options and their associated risks and benefits
• Provision of personalized health advice to the patient and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management or community-based lifestyle interventions to reduce health risks, and promote self-management and wellness.

3.)    G0439 – Annual Wellness visit: Subsequent visit, includes personalized prevention plan (PPPS).   After 11 full months have passed since the patient’s Initial Annual Wellness Visit ( G0438), the patient becomes eligible for the “Subsequent” Wellness Visit(s).  The patient can request this visit every year, after a full 11 months have passed .  The key elements performed during the Subsequent Annual Wellness Visits include:

• Updating of the patient’s medical/family history
• Updating of the list of the patient’s current medical providers and suppliers that are regularly involved in providing medical care to the patient, as was developed in the first Annual Wellness Visit (AWV), providing PPPS
• Updating of the patient’s written screening schedule as developed at the first AWV, providing PPPS
• Updating of the list of risk factors and conditions of which primary, secondary, or tertiary interventions are recommended or underway for the patient, as was developed at the first AWV, providing PPPS.
• Furnishing appropriate personalized health advice to the patient and a referral, as appropriate, to health education or preventive counseling services or programs

These preventive wellness benefits were designed by CMS to follow a logical progression in managing the health of Medicare enrollees.  There is a well-defined “introductory” visit, which is the Welcome To Medicare Visit, G0402; followed 11 months later by the Initial Annual Wellness Visit, G0438, and the Subsequent Annual Wellness Visits, G0439, to follow at intervals of roughly one year.  It’s actually a much simpler progression than it often gets credit for, and, once understood, proves to be a valuable tool for enabling providers to collaborate effectively with their mature patients on improving and maintaining good health for a longer life. You can find a summary of the requirements of all Medicare Wellness Visits on the CMS website.

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5 Recommendations for the AWV Personalized Prevention Plan

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by Lucy Lamboley

An essential element of the Medicare annual wellness visit (AWV) is the personalized prevention plan, sometimes referred to as the personalized prevention plan of service or PPPS. During the annual wellness visit, you are expected to create or update the patient's Medicare personalized prevention plan. This requirement is clearly stated, both in the regulations and AWV HCPCS codes descriptors, and yet it is often neglected. When the PPPS is overlooked, the potential ramifications are significant. Providers run the risk of experiencing claims denials, needing to return payments if shortcomings are discovered during audits, and reducing the value of the AWV and PPPS to patients.

As Medicare.gov notes , the personalized prevention plan is designed to help prevent disease and disability based on a patient's current health and risk factors. Studies, such as one conducted by the Harvey L. Neiman Health Policy Institute that was published in Preventive Medicine , found that annual wellness visits, coupled with completion of the personalized prevention plan, increase the likelihood that patients will receive preventative health services. These include undergoing mammograms, prostate cancer screenings, colon cancer screenings, and receiving the influenza vaccine.

As Danny Hughes, one of the study's authors, states in a news release, "Promoting preventive care among the Medicare population is essential to enable the elderly to stay healthy, avoid or delay the onset of disease, and live productive lives."

Medicare Personalized Prevention Plan Tips

Follow these five recommendations to improve the development of a personalized prevention plan.

1. Understand the requirements. 

If providers want to avoid the risks discussed above, they must ensure the PPPS is completed and done so properly during each AWV. Here is a summary of the core requirements:

• Produce a written preventive screening and services plan for the next 5-10 years, based on the following:
• recommendations of the United States Preventive Services Task Force; 
• recommendations of the Advisory Committee on Immunization Practices (a committee within the U.S. Centers for Disease Control and Prevention);
• individual’s health risk assessment (HRA); 
• individual’s health status;
• individual’s screening history; and 
• appropriate, Medicare-covered preventive services. 
• List patient-specific risk factors and conditions, including those identified during administration/update of the HRA, which would benefit from interventions or are already being addressed through interventions. Include mental health risks and conditions. 
• Provide personalized health advice for these health concerns and risks. 
• Identify any referrals to specialists, counseling services, and other programs

Within the regulations is the expectation that patients will be "furnished" with the personalized prevention plan and advice. While furnished is not specifically defined, it has been interpreted to mean either a physical copy of the PPPS handed to the patient upon completion of the AWV or a copy placed into a patient's active health portal account. A faxed copy is also considered acceptable if completed soon after the visit and only to address mistakes or exigencies but should never be considered part of standard workflow.

What is important to note that is that providing a copy of the HRA is not enough to qualify as a PPPS, nor is giving generic health advice that fails to speak to a patient's specific conditions. While you can provide a copy of the HRA and include generic health advice, they must be part of the more robust and patient-specific PPPS.  

2. Help patients come to you prepared

Make sure patients know the information they should bring to the annual wellness exam that will help you assemble or update a complete Medicare personalized prevention plan. If patients come unprepared, you will likely need to spend more time discussing and documenting these details and may be faced with information gaps that hinder your ability to produce an effective plan.

Information patients should come prepared with includes:

• Names of all current physicians and their specialties
• List of all current self-management and community-based interventions, including those for mental health conditions 
• Current medical records, including immunization and screening details
• Family health history

Also, ask patients to think in advance about any issues they want to discuss during their visit. This will help you better personalize the PPPS and advice you share.

3. Understand language needs

Another potential hindrance to completing the Medicare personalized prevention plan — and doing so in a timely fashion — is a language barrier. As a Centers for Medicare & Medicaid Services (CMS) report notes , an analysis of the 2014 American Community Survey (ACS), which is conducted by the U.S. Census Bureau, approximately 4 million or 8% of the 52 million beneficiaries are individuals with limited English proficiency. Spanish is overwhelmingly the most common language spoken by Medicare beneficiaries with limited English proficiency, with over half identifying Spanish as the language they speak at home.

When your staff schedule a patient's Medicare annual wellness visit, they should determine whether the patient is an individual with limited English proficiency. If so, they should work to identify the individual's preferred language and bring this to your attention. Knowing this information in advance will allow you to take the necessary steps to address such a barrier that can contribute to misunderstandings between you and the patient as well as extend the time spent on the visit. Such a step may include using language services.

4. Be prepared with a range of referral sources

As CMS notes , the personalized prevention plan should consist of referrals to educational and counseling services or programs aimed at community-based lifestyle interventions that can help reduce health risks and promote self-management and wellness. These include fall prevention, nutrition, physical activity, tobacco-use cessation, weight loss, and cognition.

To ensure the most personalized care possible, providers should have a list of options for referral sources for preventive and diagnostic services — internal and external to your organization — and work with patients to select the sources that make the most sense for their individual needs. Note: Providers are required by law to make all necessary referrals. 

Issues to consider when making these choices are as follows:

• Accessibility. How easily can the patient get to the service or program? Factors to consider might include traveling distance, parking, and mass transit. Another consideration: hours for services of programs and whether they align with the patient's schedule. Any obstacles to accessibility will likely decrease the probability that the patient follows through on the referral.
• Language. As previously discussed, language can be a significant barrier to care. If a patient requires services in a language other than English, the referred service or program should be able to accommodate this need.
• Availability. Services and programs can come and go. Make sure you are working off as current of a list of referral options as possible. If a patient pursues a service or program only to find that it no longer exists or has moved to an inaccessible location, you may not know the patient failed to follow through on the referral until the next Medicare annual wellness visit.
• Cost. A patient's ability to cover the expenses of services or programs must be a careful consideration, especially considering reports highlighting the financial struggles of many Medicare patients. Costs that need to be considered are not just any fees associated with the services or programs themselves, but also those expenses associated with transportation (e.g., gas, tolls, parking fees, taxis), childcare, and pet care.

5. Invest in technology

There is a significant amount of information to cover and document in the development of a Medicare personalized prevention plan. The more time spent on personalized prevention plan creation , the higher the cost of each annual wellness visit. In addition, documentation shortcomings can lead to coding and billing errors as well as increase audit risks.

Fortunately, providers can invest in solutions that will help automate plan development, which can reduce time to complete annual wellness visits — potentially enough to fit more patients into your schedule — while also decreasing the chance of documentation mistakes. 

One option we think you'll like is Prevounce. With the Prevounce platform, providers can streamline creation and completion of a compliant AWV with PPPS. Prevounce automates pre-visit outreach via text or email, helping patients come better prepared for their appointment and reducing the time spent by providers gathering background information. The platform simplifies the HRA, giving providers detailed information that allows them to ask more targeted questions that can help truly personalize the PPPS. Prevounce includes a personalized prevention plan creation feature that automates the plan and scheduling of preventive services. It even helps streamline billing and coding, so you receive fast, appropriate payments. Schedule a no-risk live demo now !

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Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS)

Pursuant to section 4103 of the Affordable Care Act of 2010 (ACA), the Centers for Medicare and Medicaid Services (CMS) amended sections 411.15(a)(1) and 411.15 (k)(15) of 42 CFR (list of examples of routine physical examinations excluded from coverage) effective for services furnished on or after January 1, 2011. This expanded coverage is subject to certain eligibility and other limitations that allow payment for an annual wellness visit (AWV), including personalized prevention plan services (PPPS), for an individual who is no longer within 12 months after the effective date of his or her first Medicare Part B coverage period, and has not received either an initial preventive physical examination (IPPE) or an AWV providing PPPS within the past 12 months. Medicare coinsurance and Part B deductibles do not apply

Download the Guidance Document

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: December 03, 2010

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

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Beneficiaries Utilizing Free Preventive Services by State, Year-to-Date 2011

Data: through week 47 of 2011.

*Data displayed for the most recent months may be subject to fluctuations resulting from delays in Medicare claims processing. These delays arise when there is a gap between the day a service is rendered and the day a medical provider seeks payment for that service from CMS. Generally, 90 percent of claims are received and processed by CMS within 12 weeks of service.

# - Number of beneficiaries that have received at least one preventive service in 2011 to date.

% - Share of beneficaries with traditional Medicare that have received at least one preventive service in 2011 to date.

Note: Certain services are subject to additional eligibility criteria, as outlined in the "Specifications" section below. For example, a beneficiary must be enrolled in Part B for more than 12 months to be eligible for an Annual Wellness exam.

Specifications

Appendix: list of preventive services and cpt/hcpcs codes.

Confusion about the Medicare annual wellness visit

Since its debut last year, the Medicare annual wellness visit (AWV) has been an apparent source of ongoing confusion. That point was driven home to me again this week after I reviewed some Medicare claims data for this service.

As a reminder, there are two codes related to the AWV:  G0438 (includes a personalized prevention plan of service, initial visit) and G0439 ( includes a personalized prevention plan of service, subsequent visit). As the descriptors imply, the initial AWV, should precede a subsequent AWV, and at least 11 months should have elapsed since the month of the initial AWV before a subsequent AWV can be performed and billed.

Both services became Medicare benefits effective Jan. 1, 2011. In 2011, Medicare paid for G0439 (subsequent AWV) more than 50,000 times. Given the timing of the two services and given that a Medicare beneficiary could not receive G0438 (initial AWV) before Jan. 1, 2011, it is not clear how or why any claims for a subsequent AWV (G0439) would have been processed in 2011.

I suspect that G0439 was being reported in 2011 because of confusion regarding its relationship to the Initial Preventive Physical Exam (IPPE, also known as the "Welcome to Medicare Visit"), code G0402. As noted in " When A Medicare Annual Wellness Visit Follows a Welcome to Medicare Physical ," FPM , May/June 2012, "The initial annual wellness visit must take place before a subsequent annual wellness visit in order to establish the required components that will be updated at subsequent visits. The initial annual wellness visit must occur no earlier than the same month of the year following the IPPE." In other words, the inital AWV follows an IPPE and a subsequent AWV follows an initial AWV.

Why the Medicare contractors reimbursed for G0439 in 2011 is a mystery. Apparently, they do not have the capacity or edits in place to recognize when a subsequent AWV is billed erroneously instead of an initial AWV.

For physician practices, this is more than just a matter of miscoding. It is also a matter of lost revenue. Medicare's average allowance for G0438 is $166; for G0439, it is approximately $111. That means that every time you bill G0439 when you should have billed G0438, you are leaving about $55 on the table. Maybe that's why the Medicare carriers were happy to process G0439 claims in 2011.

For more information on the AWV, check out the FPM Topic Collection on Medicare Annual Wellness Visits . 

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