j-gillAs The Centers for Medicare & Medicaid Services (CMS)  announced its record-breaking recovery effort of $4.1 billion for 2011, providers and hospitals were bracing for new depths of audits by government contractors.

The issue lists for each RAC region slowly but surely are starting to turn a critical eye toward preventative services. For primary care, this can have a significant impact on managing preventative care, according to CMS. Benefits such as annual wellness visits (AWVs) and initial preventive physical examinations (IPPEs) go against the grain of true “annual wellness” based on traditional patient care.  Furthermore, these introduce a new burden on providers by requiring them to reeducate patients on what these visits are not  – and a challenge to providers to obtain data that, in their eyes, represents a small piece of true prevention.

Years ago, CPT® developed a host of age-specific codes that, using age, risk factors and gender, scrutinized “annual wellness” in order to assess a patient’s overall heath and to develop long- and short-term plans of care. Insurance companies also long have relied on data published by the U.S. Preventative Task Force to serve as a guideline for age-specific prevention. As it did with many AMA/CPT-defined preventative services, CMS deemed these age-specific codes non-payable for Medicare beneficiaries. A host of new HCPCS codes, redefined by CMS, provide a more narrow scope of what the government deems medically necessary and payable for prevention.

In 2010 CMS announced it would be introducing an “annual wellness” series of codes to cover a more comprehensive benefit for managing patient care. As the final rule was published in 2011, providers were perplexed at the documentation requirements, as medically necessary areas such as “exam” were excluded as code components. The series of codes appears to be more of a building block for ACO models to delegate responsibility toward a primary care provider and to work toward better educating beneficiaries to take charge of portions of their own healthcare. The new codes essentially mirror IPPEs (welcome to Medicare), only with eligibility including beneficiaries presenting after the 12-month limitation. Both the IPPEs and AWVs are considered “once-in-a-lifetime” benefits.

If the benefit has been used, CMS requires a subsequent code to be billed to update patient plans of care after 11 months have passed from the original AWV service. From a compliance perspective, this becomes a billing risk, as primary care providers may not reside in the same practice and may not have the ability to validate that services have been billed and reimbursed. It came as no surprise that this was placed on the RAC issue lists for many regions starting in August 2011.

Believe it or not, there is an upside to providing IPPE/AWV services. Not only do they reimburse generously, but the guidelines also provide options in terms of who can perform the services. In a May 2011 Q&A session held by Noridian Administrative Service (a MAC), clarification was provided that not only can non-physician practitioners perform the services, but this extends to the level of RNs and LPNs if “incident-to” guidelines are met. Specific attention was directed toward qualifying the definition of “direct supervision,” and that the supervising provider must be present in the office suite and immediately available to answer questions. This could allow an RN to provide and document the AWV criteria and then allow the physician to see the patient for other medically necessary follow-up issues. If both the RN and the supervising provider perform and document two separate services, both may be billed to the carrier or MAC.

As CMS implements new benefits to cover aspects of preventative care, the carrier interpretation is vital to ensuring that services are coded and documented properly – but it also lends itself to practice variations with regard to who may provide actual services.



About the Author

Jana B. Gill, MA, CPC, is a product engineer and developer of Regulatory and Reimbursement software suites for Wolters Kluwer. Jana also is the principal of Gill Compliance Solutions, LLC which specializes in physician compliance, developing internal auditing programs, government appeals (RAC/CERT), coding risk assessments, due diligence for physician/hospital integrations and revenue analyses of hospitalist services.

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