CenCal Health has expanded its year-round Medical Record Review Program to include Dual Eligible Special Needs Plan (D-SNP) members enrolled in CenCal CareConnect. This program supports compliance with Population Health Management requirements established by the California Department of Health Care Services (DHCS) and aligns with Medicare Advantage requirements established by the Centers for Medicare & Medicaid Services, including risk adjustment and Star Ratings performance. Medical record reviews will assess whether CenCal CareConnect members receive preventive services in accordance with established clinical guidelines and whether appropriate follow-up is completed for abnormal findings. D-SNP members have specific preventive care requirements that differ from Medi-Cal members, including Medicare-specific guidelines for risk assessment, preventive screenings, and wellness visits.
IPPE and AWV Requirements for D-SNP Members:
- The Initial Preventive Physical Examination (IPPE), also known as the “Welcome to Medicare” visit, must be completed within the first 12 months following the member’s enrollment in Medicare Part B, which is required for all Medicare Advantage members.
- Annual Wellness Visits (AWVs) are required every 12 months thereafter and must include a Health Risk Assessment and a personalized prevention plan.
- AWVs focus on health promotion, disease prevention, and early identification of risk factors, and do not replace problem-focused visits.
- Identified conditions and risk factors must be addressed through appropriate diagnostic evaluation, treatment, referral, and care coordination, including behavioral health and social support services when indicated.
- AWVs may be performed in conjunction with evaluation and management services when appropriate, with proper documentation and coding.
IPPE and AWV Documentation Guidelines
- Comprehensive medical, behavioral health, and social history, including past medical/surgical history and review of systems
- Current physical and behavioral health assessment (as appropriate to visit type)
- Health Risk Assessment (HRA) with findings incorporated into the care plan
- Medication reconciliation, including supplements and over-the-counter medications
- Functional status assessment (e.g., ADLs/IADLs)
- Cognitive assessment
- Depression and substance use screening
- Review of preventive services and immunization status
- Identification of risk factors (e.g., fall risk, tobacco, alcohol use)
- Development or update of a personalized prevention plan (for AWVs)
- Advance care planning discussion (when appropriate)
- Health education and anticipatory guidance
- Diagnosis and treatment planning for identified conditions
- Documentation of member refusal of recommended services or screenings
- Documentation supporting accurate capture of chronic conditions and risk adjustment (CMS-HCC coding)
Billing Guidance
| Service Type | Description | Billing Code(s) | Key Notes |
| IPPE | Initial Preventive Physical Examination | HCPCS G0402 | For new Medicare Part B enrollees only |
| AWV | Initial Annual Wellness Visit | HCPCS G0438 | Bill once per lifetime |
| AWV | Subsequent Annual Wellness Visit | HCPCS G0439 | Bill annually after initial AWV |
| AWV + E/M | Problem‑Focused Evaluation & Management | CPT 99202–99215 | May be billed when separately identifiable and medically necessary; document services separately |
Documentation Tips: Always confirm member eligibility, record all required components, note refusals, and distinguish preventive from problem-focused care.
COMING SOON! Providers will be able to identify patients due for an IPPE or AWV via CenCal Health’s secure Provider Portal within the Coordination of Care section under the “Assignment” tab. Additional care gaps and preventive service opportunities can be found in the Quality Care Incentive Program (QCIP) section.
For more information regarding CenCal Health’s Medical Record Review Program, please contact the Clinical Quality team at: medicalrecordreviewprogram@cencalhealth.org
For additional guidance on Medicare Wellness Visits, please visit: www.cms.gov/medicare/coverage/preventive-services/medicare-wellness-visits