Highmark Medicare Advantage Medical Policy in West Virginia
Section: CMS National Guidelines
Number: N-98
Topic: Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS)(See References Section)
Effective Date: January 1, 2012
Issued Date: March 19, 2012

General Policy

Initial Annual Wellness Visit

The initial Annual Wellness Visit (AWV) providing Personalized Prevention Plan Services (PPPS) provides for the following services to an eligible member by a health professional:

  1. Establishment of an individual’s medical/family history.
  2. Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.
  3. Measurement of an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the member's medical/family history.
  4. Detection of any cognitive impairment that the individual may have as defined in this section.
  5. Review of the 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 medical professional organizations.
  6. Review of the individual’s functional ability and level of safety based on direct observation, 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.
  7. 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 United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare Advantage.
  8. Establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are 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.
  9. Furnishing 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.
  10. Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process.

Subsequent Annual Wellness Visits

In subsequent AWVs, the following services would be provided to an eligible member by a health professional:

  1. An update of the individual’s medical/family history.
  2. An update of the list of current 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.
  3. Measurement of an individual’s weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individual’s medical/family history. 
  4. Detection of any cognitive impairment that the individual may have as defined in this section.
  5. An update to the written screening schedule for the individual as that schedule is defined in this section, that was developed at the first AWV providing PPPS.
  6. An update to the list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, as that list was developed at the first AWV providing PPPS.
  7. Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs.
  8. Any other element(s) determined by the Secretary through the NCD process.

Indications and Limitations of Coverage

Members are eligible for one initial AWV (G0438) per lifetime, including PPPS:

All subsequent wellness visits must be billed as a subsequent AWV (G0439). In the event that a member selects a new health professional to complete a subsequent AWV, the new health professional will continue to bill the subsequent AWV. 

The AWV must be performed by:

The initial AWV (G0438) is paid once per member lifetime. Subsequent services reported with code G0438 are not covered.

Codes G0438 or G0439 reported within 12 months of an IPPE (G0402) or a previous AWV (G0438, G0439) are not covered.

Initial (G0438) or subsequent (G0439) AWVs, reported within the first 12 months after the effective date of the member’s Medicare coverage, are not covered.

A provider can bill the member for these denied services.

Documentation Requirements

The physician and qualified non-physician practitioners (NPPs), or healthcare professional shall use the appropriate screening tools typically used in routine physician practice. Physicians and qualified NPPs, and medical  professionals are required to use the 1995 and 1997 E/M documentation guidelines to document the medical record with the appropriate clinical information.

All referrals and a written medical plan must be included in this documentation.

Refer to Medicare Advantage Medical Policy Bulletin N-150 for additional information regarding Initial Preventive Physical Examination (IPPE) Benefits.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

G0438G0439    

Coding Guidelines

Publications

References

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-02, Chapter 15, Section 280.5

CMS Online Manual Pub. 100-04, Chapter 12, Section 30.6.1.1

CMS Online Manual Pub. 100-04, Chapter 18, Section 140

Transmittal 2119, CR 7243

Transmittal R134BP, CR 7079

Transmittal R2109CP, CR 7079

Transmittal R138BP, CR 7079

Transmittal R2159CP, CR 7079

Quick Reference Information: The ABCs of Providing the Annual Wellness Visit.

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary

TermDescription

Detection of any cognitive impairment

 

The assessment of an individual’s cognitive function by direct observation, with due consideration of information obtained by way of patient reports, concerns raised by family members, friends, caretakers, or others.

 

Eligible member

An individual who is no longer within 12 months after the effective date of his or her first Medicare Advantage coverage period and who has not received either an IPPE or an AWV providing PPPS within the past 12 months.

 

Establishment of, or an update to, the individual’s medical/family history

 

At a minimum, the collection and documentation of the following:

  1. Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments.
  2. Use or exposure to medications and supplements, including calcium and vitamins.
  3. Medical events in the member’s parents and any siblings and children, including diseases that may be hereditary or place the individual at increased risk.

 

Health Professional

 

  1. A physician who is a doctor of medicine or osteopathy (as defined in section 1861(r)(l) of the Social Security Act (the Act); or,
  2. A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act); or,
  3. A medical professional (including a health educator, registered dietitian, or nutrition professional or other licensed practitioner) or a team of such medical professionals, working under the direct supervision (as defined in CFR 410.32(b)(3)(ii) of a physician as defined in this section.

 

Review of the individual’s functional ability and level of safety

 

At a minimum, includes assessment of the following topics:

  1. Hearing impairment,
  2. Ability to successfully perform activities of daily living,
  3. Fall risk, and,
  4. Home safety.

 




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.