IPPE and AWV
Providers are reminded that the IPPE and AWV are Medicare-covered services within their own benefit category. As such, they are not subject to standard “incident to” billing guidelines and must be billed by the performing provider, whether this is a physician or NPP. There is a difference in providers who may perform these services:
- The IPPE must be performed and billed by an enrolled Medicare provider (physician or NPP).
- The AWV may be performed by a medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of medical professionals who are directly supervised by a physician (doctor of medicine or osteopathy).
- When a patient is scheduled for a follow up visit of several chronic conditions, is it allowed for the provider to separately bill Annual Wellness Visit performed on the same day?
Answer: Some chronic, stable conditions may not require assessment beyond the AWV, while others may require additional clinical examination and review or changes to the plan of care. This decision is within the realm of the performing provider’s clinical judgement. When additional history, examination and MDM is indicated to fully assess a patient’s clinical status, a separate E/M service may be performed and billed. Documentation of the E/M visit should clearly support the medical necessity of the separate service.
- When is an E/M service separately payable on the same DOS as the AWV?
Answer: The AWV has been designed as an annual overview of the patient’s health status, including elements of physical and mental health and general safety. It may be performed by clinical staff under physician or NPP supervision, and includes a review of known chronic conditions.
In some situations, the patient’s chronic (or acute) condition(s) may require evaluation and management by the primary health care provider (physician or NPP). Documentation for these services may be included in one note or in two separate notes, based on the provider’s preference. Of note, the documentation must clearly delineate all necessary details of the AWV and all necessary elements of the E/M service relative to medical necessity and level of coding.
- Please define the elements included in the AWV for assessment of chronic conditions?
Answer:As per CMS, the AWV includes routine measurement of height, weight and blood pressure and other routine measurements as deemed appropriate to the patient’s medical and family history, and does not include laboratory analysis or interpretation of laboratory values. All chronic conditions are individually assessed and a comment added regarding the status of each chronic condition.
- If the patient refuses to answer the questions of the HRA, can the AWV still be billed by the provider?
Answer: When a patient refuses to answer the HRA questions, this should be documented. If the remainder of the AWV criteria are completed and documented, the provider may bill the service.
- Is it required or recommended that the provider document “stable, deteriorated” under each diagnosis listed in their Assessment/Plan?
Answer: A comment should be entered for each diagnosis listed in the Assessment/Plan.
- Can you clarify the difference between a physical and the AWV?
Answer:A Medicare-covered AWV is intended as an overall assessment of a patient’s status, including chronic conditions, medications and scope of overall performance regarding mental acuity, psychological health and various safety and lifestyle factors.
An annual physical exam is not a covered Medicare service; E/M services other than the IPPE and AWV require a clinical complaint or reason for the visit, to support the medical necessity of the care, and are not included within the scope of covered Medicare benefits.
- Are providers required to perform IPPEs and AWVs for their Medicare patients?
Answer: CMS encourages primary care providers to offer the IPPE and AWV visits to their Medicare beneficiaries, since these are valuable preventive resources. There is, however, no mandatory requirement for providers to perform this service, nor is there a requirement for beneficiaries to avail themselves of the benefit.
- For assessment of cognitive impairment during an AWV visit, would documenting “denies focal neurological symptoms” in the ROS be sufficient?
Answer: Evaluation of cognitive impairment includes questions about the patient’s ability to perceive and understand information and his/her environment. Denial of focal neurological symptoms is not specifically relevant to cognitive function and would not suffice on this point.
- If a “medical professional” (e.g., RN) is performing an AWV, does this require physician supervision? Or can supervision be provided by a PA or NP?
Answer: When an RN performs any element of an AWV, supervision by a physician, NP, or PA is required. The supervising provider must be physically present in the office suite and immediately available to the RN.
- Does the HRA component of the Medicare AWV require a distinctly form separate from the progress note? Can a progress note simply state that a HRA was performed and provide the patient response for the required documentation points as opposed to scanning in a separate HRA form?
Answer: There is no requirement that the HRA component of the AWV be documented on a separate form. As long as all the details are fully documented in the provider’s progress note, we would consider this method of documentation to be permissible.