Billing Mistakes For Medicare Annual Wellness Visits Cost Providers

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The Centers for Medicare and Medicaid Services (CMS) has strict requirements for annual wellness visits (AWVs) and failing to include all mandated services or miscoding a claim could result in recoupments, fines, and even exclusion. Penn State Health recently paid over $11M to resolve billing mistakes on Medicare AWVs.

In this article, we outline the risks of AWV billing mistakes, along with six common AWV billing errors.

Risks of AWV Billing Errors

Coding AWVs correctly is complicated, and denials are common. But denials aren’t the only consequence at risk.

Here are some potential consequences of AWV billing errors:

  • Financial Repayments: Providers may be required to repay Medicare for any overpayments received due to billing errors. When an overpayment is identified, it becomes a debt owed to the federal government that is subject to collection efforts. These efforts can range from recoupment (garnishing future payments) to interest and penalties, and referral to the Treasury Department for further action.
  • Fines and Penalties: Depending on the severity and intent behind the errors, providers may face fines and penalties from Medicare.
  • Audits and Investigations: Billing errors can trigger audits from Medicare, which can be a lengthy and stressful process and can lead to fraud and abuse investigations. A person who “knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval” to Medicare is in violation of the False Claims Act. “No proof of specific intent to defraud” is required. Violators could face civil penalties, criminal liability, exclusion from federal health programs, and loss of their state medical licenses.
  • 60-Day Rule Violations: Providers who bill Medicare or Medicaid for services have a duty to report and return overpayments within 60 days after the date on which the overpayment was identified (or should have been identified through the exercise of “reasonable diligence”) or the date any corresponding cost report is due. Overpayments must be reported and returned if a provider identifies the overpayment within six years of the date the overpayment was received. This is known as the “60-Day Rule”. Failure to adhere to this 60-day rule can result in civil penalties and treble damages under the False Claims Act.
  • Exclusion from Medicare: In extreme cases of repeated or intentional billing errors, Medicare may exclude a provider from the program, significantly impacting their patient base.
  • Claims Rejections. In many cases, Medicare will simply deny payment for an incorrectly billed AWV. That can cause payment delays, rising collection costs, and increased service write-offs.

Common AWV Billing Errors

If you are experiencing a high number of denials for Medicare annual wellness visits, here are some common culprits to be alert for:

  1. Billing for Uncovered Services. To be eligible for AWV coverage, a patient must have Medicare Part B coverage. AWV is not covered for Plan A patients.
  2. Using the Wrong Current Procedural Terminology (CPT) Code. CMS defines two categories of wellness visits – the initial preventive physical exam (IPPE) and the annual wellness visit (AWV). The IPPE (also known as the “Welcome to Medicare” visit) is a review of the patient’s medical and social health history and an opportunity to educate and counsel the patient on preventative services. IPPEs should be billed as HCPCS G0402. The AWV is a visit to develop or update a personalized prevention plan and perform a health risk assessment. The initial AWV is billed as HCPCS code G0438. Subsequent AWVs are billed as HCPCS code G0439.
  3. Overbilling: Submitting claims for AWVs more frequently than allowed. There can only be one initial AWV (G0438) per beneficiary's lifetime, and subsequent AWVs (G0439) cannot be billed within 12 months of the previous AWV.
  4. Selecting the Wrong Diagnosis Code: Selecting a diagnosis code that doesn't reflect the purpose of an AWV (preventive health assessment) but rather a specific medical condition. The typical code for an AWV is Z00.00 (Encounter for adult preventive medicine examination).
  5. Improper Service Bundling: Billing for both an AWV and an Evaluation and Management (E/M) service during the same encounter without proper documentation. If a new medical issue arises during the AWV, you might be able to bill for both, but specific coding requirements and modifiers apply.
  6. Incomplete Documentation: Failing to document all the key elements required for an AWV in the patient's medical record. This could include the review of medical and family history, functional abilities, health risk assessment, and the development of a personalized prevention plan. Failing to complete all services is not uncommon; a 2022 study showed that nearly 20% of providers surveyed did not conduct the required health risk assessment when billing for an AWV.

Speak With A Healthcare Compliance Attorney Today

To avoid costly mistakes with AWV billing, consult the healthcare compliance attorneys at Hendershot Cowart for a bespoke risk assessment and compliance plan.

Our experienced attorneys can evaluate your billing procedures, scheduling practices, clinical workflows, and documentation practices and deliver expert advice about avoiding errors and maximizing payable claims.

Ready to tackle Medicare AWV billing issues in your medical practice? Contact the healthcare compliance attorneys at Hendershot Cowart P.C. today. Call (713) 909-7323 or contact us online 24/7.

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