LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2013-02 Recovery of Annual Wellness Visit (AWV) Overpayments





Jurisdiction 11 Part B
Recovery of Annual Wellness Visit (AWV) Overpayments

MLN Matters® Number: MM8153 Revised Related Change Request (CR) #: CR 8153 Related CR Release Date: February 15, 2013 Effective Date: July 1, 2013 Related CR Transmittal #: R1190OTN Implementation Date: July 1, 2013

Note: This article was revised on February 22, 2013, to add the transmittal number (R1190OTN) which was been omitted. All other information is unchanged.

Provider Types Affected
This MLN Matters® Article is intended for physicians and providers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), Carriers, and A/B Medicare Administrative Contractors (MACs)) for certain services to Medicare beneficiaries.

What You Need to Know
This article is based on Change Request (CR) 8153, which provides instructions to Medicare Contractors for recovering Annual Wellness Visit (AWV) overpayments that have been made.
For claims with dates of service on and after January 1, 2011, that were processed by Medicare processed on and after April 4, 2011 through March 31, 2013, Medicare systems allowed for an AWV visit (Healthcare Common Procedure Coding System (HCPCS) G0438 or G0439) on an institutional claim and a professional claim for the same patient on the same day. In some cases, this has resulted in overpayments.
CR 8107 has updated those business requirements in order to prevent future overpayments.
CR8153 instructs contractors on recovering those overpayments.

Make sure that your billing staffs are aware of these changes.

CR 7079 provided billing instructions for Annual Wellness Visit (AWV) services, which informed providers that they may provide an initial AWV visit (HCPCS code G0438) to a beneficiary once in a lifetime. In addition, providers may provide a subsequent AWV (HCPCS code G0439) if the beneficiary has not received an Initial Preventive Physical Examination (IPPE) or an AWV within the past 12 months.

For claims with dates of service on and after January 1, 2011, and processed on and after April 4, 2011 through March 31, 2013, the business requirements of CR 7079 allowed an AWV visit (HCPCS G0438 and G0439) on an institutional claim and a professional claim for the same patient on the same day. In some cases, this resulted in double billing of the same service, since institutional and professional claims may be submitted for the same service. In other instances, both a professional and an institutional claims have been received for the same patient with different dates of service exceeding the allowed services under coverage guidelines. As a response to double billing of AWV services, the Centers for Medicare & Medicaid Services (CMS) issued CR 8107 to provide instructions for edits to be modified to only allow payment for either the practitioner or the facility for furnishing the AWV. CR 8107 will be implemented on April 1, 2013. In the interim period from April 4, 2011, through March 31, 2013, double billings have occurred and may continue to occur. CR 8153 provides instructions to contractors to initiate a recovery process for these overpayments of AWV services.

Section 4103©(3)(A) of the Affordable Care Act specifically excludes the AWV from payment under the Outpatient Prospective Payment System (OPPS) and establishes payment for the AWV when performed in a hospital outpatient department under the Medicare Physician Fee Schedule (MPFS). CMS will accept claims for payment from facilities furnishing the AWV in a facility setting if no physician claim for professional services has been submitted to CMS for payment. That is, Medicare will pay either the practitioner or the facility for furnishing the AWV providing Personalized Prevention Plan Services (PPPS) in a facility setting, and only a single payment under the MPFS will be allowed. Where an AWV payment for a beneficiary has been made, this is an overpayment that must be recovered. Where these overpayments are recovered from providers, the beneficiaries will be notified that they are not responsible for reimbursing the providers for the recovered amount.

Additional Information
The official instruction, CR 8153, issued to your Carrier and A/B MAC regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1190OTN.pdf on the CMS website.

To review the initial MLN Matters® article, MM7079, that describes the AWV along with the particulars of the Personalized Prevention Plan Services (PPPS) go to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7079.pdf on the CMS website.

To review the MLN Matters® article, MM8107, that describes the modified billing instructions for an AMW visit, go to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8107.pdf on the CMS website.

This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2012 American Medical Association.

last updated on 02/25/2013