Under the Affordable Care Act, Medicare beneficiaries are eligible to receive an Annual Wellness Visit. This type of visit is a yearly office visit that focuses on preventive healthcare. Providers should review risk factors, and develop a personalized prevention plan of care for the patient. The overarching goal is for Medicare to begin providing more value based services rather than services in which a patient is ill and needs treatment. Although this new Annual Wellness Visit does not cost anything to the beneficiary, and could be a significant portion of your revenue for the upcoming years, it is important to remember the compliance risks associated with the Annual Wellness Visits.
Compliance Concerns
As with any reimbursement under a Federal health care program, there are specific requirements that must be met in order for your organization to bill for the services. If these requirements are not met, then you may have specific fraud and abuse concerns. Nevertheless, it is important to analyze each component to avoid those compliance and legal issues. The following are various issues that should be addressed when beginning your Annual Wellness Visit program.
Who may bill for the Annual Wellness Visit?
Under the Medicare regulations, a physician (MD or DO), a nurse practitioner, physician assistant, or clinical nurse specialist may provide the professional services. Further, it is permissible for a medical professional (dietitian, health educator, or other licensed practitioner) to provide the service so long as the individual is under the direct supervision of a physician.
What is included in the initial Annual Wellness Visit?
Medicare has outlined the various components of the entire service below. Although these requirements are substantial, it is necessary to meet each specific requirement for payment.
- Establishment of an 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 an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history.
- Detection of any cognitive impairment that the individual may have as defined in this section.
- Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations.
- Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations.
- Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
- Establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
- 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, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
- Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process.
What is included in the subsequent Annual Wellness Visit?
Medicare has outlined the various components that must be included in subsequent Annual Wellness Visits. The following are included in those requirements:
- An update of the individual’s medical/family history.
- An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing PPPS.
- Measurement of an individual’s weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individual’s medical/family history.
- Detection of any cognitive impairment that the individual may have as defined in this section.
- An update to the written screening schedule for the individual, as that schedule is defined in this section, that was developed at the first AWV providing PPPS.
- An update to the list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, as that list was developed at the first AWV providing PPPS.
- Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs.
- Any other element(s) determined by the Secretary through the NCD process.
What are the Coding Requirements for an Annual Wellness Visit?
Medicare allows each beneficiary to be billed for one HCPCS Code under G0438 for their initial Annual Wellness Visit. CMS has stated that it can only be paid once and will be denied if it is billed for a second time. However, for subsequent Annual Wellness Visits the HCPCS Code is G0439. This can be billed in subsequent years.
Takeaway Points
Billing for Annual Wellness Visits can certainly bring increased revenue to your organization; however, Medicare has provided various requirements to ensure that the Annual Wellness Visit is up to the standards of what it deems is worthy of payment. Therefore, organizations should be mindful of these requirements, educate their practitioners on these requirements, and ensure that the correct types of practitioners are providing the services.