May 25, 2023
Targeted Probe and Educate Program to Focus on Annual Wellness Visits
The CGS Targeted Probe and Educate (TPE) program will begin a review of claims associated with annual wellness visits (AWVs). Coverage and billing guidance is available in the resources listed below.
AWV claims must meet all medically reasonable and necessary requirements outlined in the applicable statute, regulations and manual provisions.
We expect the documentation you submit to include a copy of the following information from each patient’s medical record that is legible and signed:
- Beneficiary’s name
- Date of service
- Signed medical records that establish:
- Medical/family history
- Medications and supplements used
- List of providers and suppliers
- Cognitive assessment
- Depression screening
- Functional ability and safety
- Screening schedule for beneficiary testing
- List of risk factors and conditions
- Counseling programs for health risks
- For subsequent annual wellness visits, a notation that medical/family history and health risk assessment were reviewed and updated, if needed
- Copy of any mandatory ABNs
- Appropriate signatures
- Signature and credentials of person performing the service must meet CMS requirements
- Amendments/corrections/delayed entries are properly identified
For additional documentation requirements, please reference:
- CMS IOM Pub. 100-04, Chapter 12, Sections 30.6.1.1, 30.6.6 and 100.1.1.C
- CMS IOM Pub. 100-04, Chapter 18, Section 140
- CMS IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15
- MLN6775421 – Medicare Wellness Visits (cms.gov)
CPT codes under review will include:
- G0438 – Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit
- G0439 – Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit
For more information on the TPE program, please reference:
- CGS Targeted Probe and Educate (TPE) webpage
- CGS Targeted Probe and Educate (TPE) Process webpage
- Targeted Probe and Educate: Did You Know?
- CMS Targeted Probe and Educate webpage
We encourage you to use the myCGS portal to identify claims selected for review and submit your documentation. For more information, including step-by-step instructions, please reference the myCGS User Manual.