Providers take note: Survey on annual wellness visit shows significant non-compliance

The survey's findings suggest that many AWVs conducted and billed may fail to meet compliance requirements set forth by CMS.

If your medical practice provides annual wellness visits (AWV) for Medicare beneficiaries, recently published survey results suggest that you should verify your procedure and the tools you're using are effectively satisfying Medicare requirements.

The survey was conducted by the American Academy of Family Physicians' research network in March 2019. It was completed by 159 primary care providers from 145 practices in 36 states. The survey's intent was to examine the variability in assessments and tools used during the yearly AWV appointment.

The AWV is a Medicare-covered service that enables beneficiaries to receive an annual wellness exam (not a physical) at no out-of-pocket cost. For patients, it helps better connect them with appropriate health services and develop a preventive health plan with their provider. For providers, it helps increase communication with patients, increase patient compliance rates, and increase revenue opportunities.

The survey's findings suggest that many AWVs conducted and billed may fail to meet compliance requirements set forth by CMS. Results showed that about 1 in 5 respondents are failing to use an HRA, which is a fundamental and required component of the AWV. Only about half of respondents indicated they had performed a required home safety assessment, while more than 2 in 5 indicated they were not performing the required nutritional/diet assessment. Survey results also pointed to noteworthy shortcomings establishing a list of current physicians and providers regularly involved in the patient's medical care, addressing cognitive function, and several other areas. The results were published in the May 2022 issue of the Journal of the American Board of Family Medicine.

At its most technical level, more than 4 in 5 AWVs in the survey were non-compliant. This figure comes from 16% of providers are performing a driving safety assessment. The AWV conditions for coverage stipulate that "motor vehicle safety (seat belt use)" is a behavioral risk topic that must be evaluated as part of the required health risk assessment (HRA). Thus, a practice failing to address this seemingly small area may risk AWV non-compliance.

If required elements are not completed and documented, the AWV can be considered non-compliant by an auditor. Potential ramifications include clawbacks and other penalties, while egregious and willful cases could see practices facing exclusion from Medicare or criminal liability.

Why is AWV compliance proving so difficult for practices?

The AWV process seems straightforward. The challenge is that the annual wellness visit requires providers to furnish multiple services to eligible beneficiaries, with those services identified in the AWV conditions for coverage.

The initial AWV requires practices to document the following:

  • HRA
  • Medical and family history
  • Current healthcare providers and suppliers
  • Routine, essential measurements (e.g., height, weight, body mass index/waist circumference, blood pressure, and others deemed essential as per the beneficiary's medical and family history)
  • Cognitive function
  • Potential risk factors for depression
  • Functional ability and safety
  • Written preventive screening schedule for the beneficiary's next 5-10 years (which is considered an integral part of the required personalized prevention plan of service (PPPS))
  • Risk factors and conditions for which an intervention is recommended or already underway
  • Personalized health advice and referrals
  • Advance care planning (ACP) services (upon request)

Subsequent AWVs require the following documentation requirements:

  • Updated HRA
  • Updated beneficiary's medical/family history
  • Updated list of current healthcare providers/suppliers
  • Routine, essential measurements
  • Completed cognitive function assessment
  • Completed depression/risk factor discussion
  • Updated written screening schedule
  • Updated risk factors/conditions for which interventions are recommended/underway
  • Updated the PPPS, including personalized health advice and referrals to health education and/or preventive counseling services or programs, as appropriate
  • Reviewed/discussed ACP services (at the patient's discretion)

While these lists of requirements appear long, completing most of them — particularly following completion of a patient's initial AWV — will typically not require significant time for providers. But whether required components take 30 seconds or 10 minutes to complete does not matter. What matters is that they are completed and documented appropriately.

What should practices do to better ensure AWV compliance?

As stated earlier, verify the tools your practice uses for AWVs prompt providers to complete all required components. There are solutions on the market that do so and can generate the comprehensive documentation necessary in the event of a chart check or audit.

Without such a tool, your AWVs are inherently more likely to miss one or more components and be non-compliant. Failure to complete documentation requirements not only increases the likelihood AWVs being found non-compliant by an auditor, but you are more likely to have AWV claims denied. This will delay your reimbursement and grow the costs associated with billing for the service, including staff time and reprinting documentation.

Daniel Tashnek is the co-founder of Prevounce Health, a healthcare software company that simplifies the provision of preventive medical services, chronic care management and remote patient management. Daniel is also a practicing healthcare attorney specializing in regulatory compliance, reimbursement, scope of practice, and patient care issues.