Annual Wellness Visit
Insufficient documentation means that something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for an annual wellness visit:
- Missing list of providers and suppliers involved in the patient’s care.
- Missing a screening schedule.
- Missing a behavior risk assessment.
- Missing electronic signature or legible signature of the performing provider.
Providers involved in patient care: A list of current providers and suppliers that are regularly involved in providing medical care to the individual.
Screening schedule: A written screening schedule for the individual, such as a checklist for the next five to ten years, as appropriate, based on recommendations of the USPSTF and the ACIP, and the individual’s health risk assessment (as that term is defined in this section), the individual’s health status, screening history and age-appropriate preventive services covered by Medicare.
Behavior risk assessment: A 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.
Signature: An electronic signature or legible signature is required on medical records.
Related Content
- Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 280.5 (Annual Wellness Visit)
- CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (Signature Requirements)
- MLN Matters Booklet: Annual Wellness Visit