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Meeting Medicare AWV Compliance Requirements


Many medical practices are billing for Medicare's AWV without providing a detailed and personalized plan at the visit. Here's what they should do.

I've met physicians who think they are complying with the requirements of the Medicare Annual Wellness Visit (AWV), but don't realize they have to provide a personalized plan at the time of the patient visit.

Providers must provide at least one “action” for all health risks discovered for the patient from the required pre-visit Health Risk Assessment. The complete “personalized care plan” must be created and given to the patient at the time of the visit and cannot be sent later.

Actions required are identified in the CMS bulletin MM7079 as:

1. Written 5-year to 10-year screening schedule, health status, screening history, and age-appropriate preventive services covered by Medicare;

2. Personalized health advice given to the individual;

3. Referral to health education or preventive counseling services or programs aimed at reducing identified risk factors; and

4. Community based life-style interventions, i.e., weight loss, physical activity, smoking cessation, fall prevention and nutrition, etc.

Therefore, practices should engage an IT service to create all the “actions” that the practice pre-determines for most potential health risks and personalize them to specific local and in office sources.

Actions can further be identified, for example, as:

1. Referral to local senior center for exercise programs with specific phone and location information provided.

2. In-office appointments for smoking (G0437), obesity (G0447), or alcohol counseling (G0443) reimbursed on new preventive codes.

3. Referral to office-recommended orthopedist, eye specialist, or nutritionist.

4. Return appointments to go over nocturnal problems, allergy, falling, or other concerns discovered on the Health Risk Assessment as they are offered by the provider.

CMS specifically does not accept “general” health recommendations, such as “exercise more, eat less, smoke and drink less, etc.” Providers must search their local referrals databases and create a library of community programs with details on their location, phone, etc., to give to the patient at the time of the visit.

It is important to note that the provider should not specifically address any of these concerns at the time of the visit since they are not reimbursed if provided at that time. The AWV is only reimbursed for “planning and referrals” and not for any treatment or even prescriptions. If an emergency condition is discovered, the provider is allowed to and should extend the time and bill for a 99213 or other appropriate code with a -25 modifier to treat that condition on the same day.

One caution is that CMS is launching audits under its Recovery Audit Contractors (RACs) to discover improper or incomplete provision of the AWV. Many practices are simply billing for the AWV without providing a detailed and personalized plan at the time of the visit.

Providers should consider a qualified IT partner to create these personalized plans with pre-determined local referrals and in-office actions to pass an audit and prevent recapture of the AWV revenue.

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