CMS releases transmittal with details on new wellness visits

You've got the details of annual wellness visit in writing, thanks to a CMS transmittal released Dec. 3. There are few surprises in the 35-page document, which is effective Jan. 1, the same day you can first start billing Medicare for this service.

Transmittal 2109 does offer a full list of the remittance advice codes you'll see in the unhappy scenario that your annual wellness visit (AWV) gets denied. While we have written extensively about the major requirements that could cause an early, edit-based denial of the AWV, knowing exactly how the error codes will read may help expedite your appeal efforts.

Here's a breakdown, with special attention on the new codes.

Denial occurs because you bill an initial AWV for a patient who already received an initial AWV:

• CARC 149: "Lifetime benefit maximum has been reached for this service/benefit category."
• RARC N117: "This service is paid only once in a patient's lifetime.
• MSN 20.12: "This service was denied because Medicare only covers this service once a lifetime."

• (New) MSN 18.27: "This service was denied because it occurred too soon after your Initial Preventive Physical Exam."
• (New) MSN 18.24: "This service was denied. Medicare doesn't cover an Annual Wellness Visit within the first 12 months of your Medicare Part B coverage. Medicare does cover a one-time initial preventive physical exam ("Welcome to Medicare" physical exam) within the first 12 months of your Medicare Part B coverage".
• CARC 119: "Benefit maximum for this time period or occurrence has been reached."
• RARC N130: "Consult plan benefit documents/ guidelines for information about restrictions for this service."

While these are mostly reworded versions of language from the 2011 final Physician Fee Schedule (PFS), here are the official requirements from Transmittal 2109. For details on what these actually mean in the exam room, check out Part B News' earlier stories on the wellness visit.

Requirements for initial AWV (G0438):

• Establishment of the individual's medical/family history,
• Measurement of the individual's height, weight, body mass index (or waist circumference, if appropriate), blood pressure (BP), and other routine measurements as deemed appropriate, based on the individual's medical and family history,
• Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual,
• Detection of any cognitive impairment that the individual may have,
• Review of an individual's potential risk factors for depression , including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national professional medical organizations,
• Review of the individual's functional ability and level of safety, based on direct observation of the individual, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available
• screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations,
• Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the USPSTF and Advisory Committee of Immunizations Practices (ACIP), the individual's health status, screening history, and age-appropriate preventive services covered by Medicare,
• Establishment of a list of risk factors and conditions of which primary, secondary, or tertiary interventions are recommended or underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits,
• Provision of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition,
• Voluntary advance care planning upon agreement with the individual,
• Any other element(s) determined appropriate by the Secretary through the NCD process.

Requirements for subsequent AWV (G0439):

• Update to the individual's medical /family history,
• Measurements of an individual's weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individual's medical and family history,
• Update to the list of the individual's current medical providers and suppliers that are regularly involved in providing medical care to the individual as that list was developed for the first AWV providing PPPS,
• Detection of any cognitive impairment that the individual may have,
• Update to the individual's written screening schedule as developed at the first AWV providing PPPS,
• Update to the individual's list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, as that list was developed at the first AWV providing PPPS,
• Furnish appropriate personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs,
• Voluntary advance care planning upon agreement with the individual, and,
• Any other element determined appropriate by the Secretary through the NCD process.