OBJECTIVES THE MEDICARE ANNUAL WELLNESS VISIT Learn the required components of the AWV Consider the benefits to the patient and primary care provider Discuss the logistics of performing the AWV Learn appropriate billing for the AWV Malissa G. Talbert, MD June 14, 2018 GENESIS OF THE AWV Medicare does not cover routine physical examinations. -cms.gov The Affordable Care Act provided for an Annual Wellness Visit, including Personalized Prevention Plan Services (PPPS) for Medicare beneficiaries as of January 1, 2011 The AWV will include the establishment of, or update to, the individual s medical and family history, measurement of his or her height, weight, body-mass index (BMI) or waist circumference, and blood pressure (BP) Goal is health promotion and disease detection and fostering the coordination of the screening and preventive services that may already be covered and paid for under Medicare Part B MLN MATTERS NUMBER: MM7079 WHAT IS SPECIAL ABOUT THE AWV? The AWV is an opportunity for the provider to: An ounce of prevention is worth a pound of cure. -Benjamin Franklin Consider issues that may be overlooked in a typical physical exam Engage with patients on a regular basis, and detect emerging health and safety risks Review the patient s complete medication list and identify any potential adverse drug events 1
TYPES OF ANNUAL WELLNESS VISITS Initial Preventive Physical Exam (IPPE) Commonly known as the Welcome to Medicare visit Once in a lifetime benefit for Medicare Part B enrollees Occurs within the first 12 months of Medicare enrollment No co-insurance/co-pay or Medicare Part B deductible for patient Does not require a specific diagnosis TYPES OF ANNUAL WELLNESS VISITS (cont.) ANNUAL WELLNESS VISIT Patient is no longer within 12 months of Medicare enrollment Patient has not received either an IPPE or AWV within the past 12 months No co-pay or deductible for patient Does not require a specific diagnosis HEALTH RISK ASSESSMENT Medicare requires a patient to complete a comprehensive Health Risk Assessment (HRA) to evaluate their current health status, evaluate risk of disease or disability, and assess safety risks in the home Must be tailored to the patient s communication needs Should take no more than 20 minutes to complete Patient may complete in advance of the visit HEALTH RISK ASSESSMENT (cont.) Medicare does not require a specific HRA form, but the document must meet the following requirements: Demographic data Self-assessment of health status Psychosocial and Behavioral Risks Activities of Daily Living (ADL) dressing, bathing, walking Instrumental ADLs - shopping, medication management, housekeeping, handling finances MINIMUM REQUIREMENTS OF THE AWV Other minimum requirements of the AWV include: Vitals such as height, weight, blood pressure, and BMI IPPE requires visual acuity screening List of current providers and suppliers Document the patient s medical history and family medical history Evaluate the patient for potential risk factors for depression Screening for fall risk, home safety and hearing impairment MINIMUM REQUIREMENTS OF THE AWV (cont.) Other minimum requirements of the AWV include: Update medication list, including supplements Screen the patient for cognitive impairment Screen for potential substance misuse such as alcohol, tobacco, or narcotics Establish a written screening schedule, such as a checklist for the next 5-10 years, as appropriate Provide personalized health advice and make appropriate referrals to health education or preventive counseling services 2
WHO CAN PERFORM THE IPPE? Physician A qualified non-physician practitioner Physician s Assistant (PA) Nurse Practitioner (NP) Certified clinical nurse specialist WHO CAN PERFORM THE AWV? Physician Qualified non-physician practitioner Medical professional Health educator Registered dietician Nutrition professional Other licensed practitioner Team of medical professionals who are directly supervised by a physician BASIS OF RECOMMENDED SCREENINGS/VACCINATIONS Beneficiary s HRA, health status and screening history Recommendations from the US Preventive Services Task Force (AHRQ epss app) Recommendations from the Advisory Committee on Immunization Practices Age-appropriate preventive services covered by Medicare BENEFITS OF THE AWV Patient Benefits More likely to receive evidence-based screening and preventive services Reduce risk of chronic disease Add years to the patient s lifespan Prevent accidents at home Keep patients out of the hospital Delay long term care Carves out time for shared decision-making BENEFITS OF THE AWV Provider Benefits Opportunity to build a complete medical history for chronically ill patients Improve patient engagement and promote preventive health care Allows time for a nuanced discussion of benefits/risks of screening tests Increase quality metrics Create a new revenue stream for the practice 3
-25 MODIFIER USE If you furnish a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service along with the AWV, Medicare may pay for the additional service per cms.gov That portion of the visit must be medically necessary to treat the beneficiary s illness or injury, or to improve the functioning of a malformed body member. Report the additional CPT code with modifier -25 Alert the patient co-pay/deductible will be required NEW FOR 2018 PROLONGED PREVENTIVE SERVICES CODES G0513 Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service) G0514 Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code G0513 for additional 30 minutes of preventive service) Pertains to physician/pa/np time spent, not staff time Each reimburses additional $62.28 MLN Matters Number: MM10393 IMPLEMENTATION HURDLES Identifying and capturing the eligible patients Staff training Staff buy in Medicare patient uninformed about IPPE/AWV Mail info packet in advance Refer the patient to medicare.gov Patient scheduling issues Scheduling the correct visit Scheduling on the correct date Time allotment IMPLEMENTATION HURDLES (cont.) Work flow Staffing issues Division of labor Staff numbers Staff training Completion of HRA Encourage patient to complete in advance Alternately, the HRA can be done electronically at home or on site Selecting the correct CPT code for billing IPPE Initial AWV Subsequent AWV TOOLS AND RESOURCES AAFP (aafp.org) FPM Medicare Wellness Visit Toolkit Several pertinent journal articles American College of Physicians (acponline.org) ACP Tools for the Annual Wellness Visit CMS.gov The ABCs of the Initial Preventive Physical Examination The ABCs of the Annual Wellness Visit OPTIONAL ELEMENT OF THE AWV ADVANCE CARE PLANNING (ACP) Face-to-face conversation between the provider and the beneficiary to discuss the beneficiary s wishes and preferences for medical treatment if he or she were unable to speak or make decisions in the future Takes place at the beneficiary s discretion ACP CPT codes 99497 first 30 min; with patient, family member, and/or surrogate 99498 each additional 30 min When ACP is provided at the time of the AWV, the co-pay and deductible for the ACP are waived ACP can be provided at any other visit, but co-pay and deductible are not waived 4
CPT CODES IPPE G0402 1 st AWV G0438 Subsequent AWV G0439 ACP 99497 (first 30 min) AWV NUTS AND BOLTS EMR/EHR AWV templates are useful What diagnostic ICD10 code should be used to code the visit? Medicare does not require a specific diagnostic code for either the IPPE or AWV You may choose any diagnostic code consistent with the beneficiary s exam Labs are not included in either the IPPE or AWV. If done, the costs will apply to the patient s deductible and co-pay If a screening EKG is done during the IPPE, the co-pay and deductible are not waived for the EKG Don t forget the personalized prevention plan ACP 99498 (each add l 30 min) REFERENCES Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS) MLN/MLNMattersArticles/downloads/MM7079.pdf The ABCs of the Initial Preventive Physical Examination (IPPE) MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf The ABCs of the Annual Wellness Visit (AWV) MLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdf REFERENCES (cont.) Hoover M and Palmer W. (Sept 2017) Medicare s Annual Wellness Visit: A Framework for Quality Patient Care (PPT slides). https://www.atomalliance.org/wp-content/.../awv-presentation_2017-regional- Meetings.pptx FAQ on the Medicare Annual Wellness Visit (AWV) and the Initial Preventive Physical Examination https://www.aafp.org/practice-management/payment/coding/medicarecoordination-services/awv/faq.html#why should i consider implementing medicare's annual wellness visits? Medicare Preventive Services Chart https://www.cms.gov/medicare/prevention/prevntiongeninfo/medicare-preventiveservices/mps-quickreferencechart-1.html 5