Annual Wellness Visit - Healthcare Common Procedure Coding System (HCPCS) G0438 and G0439 - JF Service Specific Targeted Review Interim Findings

Current Review Results

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs post-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for HCPCS G0438 annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit and HCPCS G0439 annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit.

The results of this focused review are not a reflection on providers’ competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility’s compliance with the required documentation.

Summary of Findings

Since the initiation of the review, 25 claims were reviewed from October 1, 2020 through December 31, 2020. The breakdown of those findings are as follows:

  • 18 claims were allowed.
  • 7 claims were denied in full for the following reasons:
    • The service was denied because the documentation did not support all of the requirements of an annual wellness visit

The overall error rate since the initiation of this service specific targeted review is 25.63%. The error rate is calculated by dividing the dollar amount of charges billed in error (minus any confirmed under-billed charges) by the total amount of charges for services medically reviewed. If you disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice, although this will not affect the error rate of the post-payment review.

Education

Medicare covers an Annual Wellness Visit (AWV) for all beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period, and who have not had either an IPPE or an AWV within the past 12 months. Medicare pays for only one initial AWV per beneficiary per lifetime and one subsequent AWV per year thereafter.

The requirements of the annual wellness visits can be found in the Code of Federal Regulations (CFR), title 42, section 410.15.

Initial (G0438) and subsequent (G0439) AWV Components, at a minimum, must, address/update the following topics:

  • Demographic data
  • Self-assessment of health status
  • Psychosocial risks
  • Behavioral risks
  • ADLs, including but not limited to: dressing, bathing and walking
  • Instrumental ADLs, including but not limited to: shopping, housekeeping, managing own medications, and handling finances
  • Hearing impairment
  • Fall risk
  • Home safety

When billing an Evaluation and Management (E&M) code on the same day as the AWV:

  • The E&M must be significant and separately identifiable in the documentation
  • The E&M must medically necessary to treat the patient's illness or injury, or to improve the functioning of a malformed body member.

Resources

For additional educational resources, please visit our Education and Outreach department.

Provider Action Required

Providers should review individual claim determinations.

To review individual claim comments via the Noridian Medicare Portal, complete the following steps:

  1. Log into Noridian Medicare Portal at https://www.noridianmedicareportal.com/
  2. Choose Claim Status from the menu bar.
  3. On the Claim Status Inquiry page:
    1. Fill in all Provider/Supplier Details.
    2. Select MEDB under Program drop down box
    3. Fill in all Beneficiary Details
    4. Fill in Claim Details.
  4. Click the Submit Inquiry button at the bottom of the form.
  5. On the Claim Status Results page
    1. Choose View Claim.
    2. On the right side of the page will the heading: Related Inquiries
    3. Choose Noridian Comments.
  6. Scroll down the page and under the Claim Status Line Details the comment will display.

Note: If documentation was sent late (>45 days from the date of the ADR), the claim may have been reopened by the examiner. These reviews are not currently available on the portal.

Initial documentation must be sent by fax, mail or esMD. Additional documentation requested can be submitted fax, mail or Noridian Medicare Portal.

Further provider action recommended includes:

  • Provide education regarding errors noted to applicable staff members.
  • Verify documentation supports medical necessity of HCPCS G0438 and G0439.
  • Ensure ADR submissions are timely, complete, and include all documentation to support medical necessity and a valid physician order.
  • If records supporting the services on the claim are located at another facility, as the billing provider, your facility is responsible for obtaining those records for review.

Summary

This service specific targeted review will continue until medical review results demonstrate provider compliance with Medicare guidelines and education provided. This file is reviewed at least quarterly; providers with low/no errors after a reasonable sample will no longer be reviewed for this file. Remaining providers will continue to be reviewed.

If you would like to receive information regarding findings specific to your facility prior to the completion of the review, send an email to medicalreviewb@noridian.com. In order to facilitate the response, follow these instructions:

  • Complete the Subject line with the following information: Results request for HCPCS G0438 and G0439 targeted review
  • In the body of the email, include the following elements:
    • Your name, title, and telephone number
    • The facility name
    • NPI Number
    • Short description of information you would like to receive
  • Indicate if you would like to receive results via phone call, fax or US Mail and include a fax number or mailing address as applicable.

Upon request receipt, Noridian Medical Review will respond as timely as possible. Requests may take up to two weeks to be completed.

If you have any questions, contact the Provider Contact Center

 

Last Updated Mon, 08 Feb 2021 16:11:24 +0000