While Medicare Part B does not provide coverage for Preventive Medicine (CPT code range of 99381 through 99397), the Affordable Care Act ("ACA") integrated two new and unique preventive and wellness services compensable under Medicare as follows:
- Initial Preventive Physical Exam ("IPPE") also known as the Welcome to Medicare Preventive Visit and;
- Annual Wellness Visit ("AWV").
SunStone Consulting has found misconceptions exist among primary care providers regarding use of the two preventive services. The overarching element which differentiates both services from a routine physical exam is disease prevention in the context of individualized risk, early detection, health education and health counseling. Rendering, documenting and billing what is generally thought of as a preventive medicine exam but using the IPPE HCPCS code G0402 and the AWV HCPCS code G0438 for the first visit (HCPCS code G0439 for subsequent years), could pose risk for providers.
Below, we highlight the major components outlined by the Centers for Medicare and Medicaid Services ("CMS") which will help to ensure appropriate documentation, coding and payment for these services.
IPPE - Welcome to Medicare Preventive Visit
The IPPE may contain overlapping service elements of a "traditional" routine physical examination such as body measurements and blood pressure. The IPPE differs however in several notable areas, per the Medicare Claims Processing Manual, Chapter 12, Section 126.96.36.199, as follows:
- Review of the individual's medical and social history with attention to modifiable risk factors for disease detection.
- Review of the individual's potential (risk factors) for depression or other mood disorders using an appropriate screening instrument.
- Review of the individual's functional ability and level of safety including, at a minimum, the individual's fall risk, activities of daily living, home safety and hearing impairment.
- Examination to include measurement of the individual's height, weight, body mass index, blood pressure, a visual acuity screen, and other factors as deemed appropriate, based on the individual's medical and social history.
- End-of-life planning, with agreement by the individual.
- Appropriate education, counseling, and referral, based on the results of the review and evaluation services described in the previous five elements.
- Education, counseling, and referral including a brief written plan (e.g., a checklist or alternative) provided to the individual for obtaining the appropriate screening and other preventive services, which are separately covered under Medicare Part B.
Annual Wellness Visit (AWV)
The focus of the AWV is the development of the individual's personal prevention plan. The AWV is compensable to primary care providers utilizing HCPCS codes G0438; annual wellness visit, first visit and G0439; annual wellness visit, subsequent visit.
Incorporating a Health Risk Assessment ("HRA") is a fundamental component of the AWV's individual personal prevention plan. CMS directs providers to the Centers for Disease Control to select an appropriate risk assessment tool. CMS requires that providers administer and review the HRA, and document the following for a beneficiary's initial AWV:
- Establishment of the individual's medical/family history.
- Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.
- Measurement of the individual's height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other appropriate measurements based on the individual's medical and family history.
- Detection of any cognitive impairment.
- Review of an individual's potential risk factors for depression.
- 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 or a screening questionnaire.
- Establishment of a written screening schedule for the individual, based on recommendations of the United States Preventive Services Task Force ("USPSTF") and Advisory Committee of Immunizations Practices ("ACIP"), and the individual's health risk assessment, health status, screening history, and age-appropriate preventive services covered by Medicare.
- Establishment of a list of risk factors and conditions of which primary, secondary, or tertiary interventions are recommended or underway for the individual.
- Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management.
All elements of the initial AWV must be updated annually to support billing HCPCS code G0439 to include:
- Updated HRA.
- Updated medical/family history.
- Current provider and supplier list.
- Measurement of an individual's weight (or waist circumference), blood pressure, and other appropriate routine measurements based on the individual's medical and family history.
- Detection of any cognitive impairment.
- Update to the individual's written screening schedule as developed at the first AWV.
- Update to the individual's list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual.
- Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs.
It is essential that providers and health care administrators understand that both the IPPE and AWV encompass specific and distinct elements, which set them apart from a routine physical exam. Incorporating a comprehensive process to appropriately capture and document IPPE and AWV services promotes quality, while also ensuring appropriate charge capture and mitigating risk.
For more information regarding our Professional Revenue Cycle Solutions, or IPPE and AWV, please contact Vonda Moon at 717-676-6133.