Warning lights are flashing around annual wellness visits, one of the top reasons for repeated failures in Targeted Probe and Educate (TPE), the prepayment medical reviews by Medicare administrative contractors (MACs). Claims are doomed when physicians don’t document one or more of the required elements of annual wellness visits. On the flip side, some physicians are leaving money on the table by not performing them at all, possibly because they’re unfamiliar with the overarching purpose and specific requirements of annual wellness visits or confuse them with the Welcome to Medicare visit, experts say.

Perhaps because of noncompliance, CMS on Nov. 5 updated its guidance^[1] on annual wellness visits and Welcome to Medicare visits, and added answers to frequently asked questions. Annual wellness visits were in the top five items and services that led to CMS referrals after providers failed three rounds of TPE audits, said Dan Schwartz, director of CMS’s Division of Medical Review, at the virtual CMS Provider Compliance Focus Group Oct. 19.^[2] Although TPE is temporarily on hold because of the COVID-19 public health emergency, he said it will be back.

Physician practices could improve their compliance and revenue by having one template for the Welcome to Medicare visit, annual wellness visit and subsequent wellness visits because “it’s a systemic problem that needs to be solved,” said Betsy Nicoletti, a consultant in Northampton, Massachusetts.

The purpose of the Welcome to Medicare and annual wellness visit is not to perform routine physicals, which are explicitly prohibited by the Social Security Act, according to the FAQs. “An annual wellness visit is this amazing component that is not performed properly a lot of the times,” said Christine Hall, president of Stirling Global Solutions in Florida. “It’s not a physical, it’s a social and clinical picture of the patient.” Are the patients a fall risk, and do they have grips on their stairs? Do they need counseling for sexually transmitted diseases? Who is their cardiologist? “Annual wellness visits reimburse well because you’re looking at the patient from a general perspective. What can we prevent from happening in the next 12 months?” Hall said. “This is painting a picture of a patient.”