Leveraging Wellness Visit with Medicare: Improving Income and Patient Outcomes

Overview Why Medicare Wellness Exams What are the Medicare Wellness Exams Annual Wellness Exam Components What is covered by the Medicare for wellness How to code for the Medicare Wellness Exams

Why Wellness Exams Enhanced reimbursement ($172) Performed by mid-level Improve patient outcomes Collect PQRS and MU data Prepare for CMS Value Modifier 3

Who Can Perform AWV Medicare Part B covers the Annual Wellness Visit (AWV) if it is furnished by a: Physician (doctor of medicine or osteopathy) Physician assistant Nurse practitioner Clinical nurse specialist Medical professional (including a health educator, a registered dietitian, nutrition professional, or other licensed practitioner) or a team of such medical professionals working under the direct supervision of a physician (doctor of medicine or osteopathy) 4

What are Wellness exams In the words of CMS: CMS is committed to promoting the appropriate use of Medicare preventive services. Medicare now covers a broad range of services to prevent disease, detect disease early when it is most treatable and curable, and manage disease so that complications can be avoided CMS recognizes the crucial role that health care providers play in providing and educating Medicare beneficiaries about potentially life-saving preventive and services and screenings.

What is Covered Preventive services Initial Preventive Physical Exam (IPPE) AKA Welcome to Medicare Preventive Physical Annual Wellness Visit (AWV) Screenings Vaccinations Behavior therapy and counseling

Annual Wellness Visit (AWV) Initial visit vs Subsequent visit Not within 12 months of starting benefits or last IPPE/AWV Copay/Coinsurance: No Elements History: The patient s past medical, surgical and family history, including medications and supplements, and current providers. Assessment: The patient s height, BMI (initial AWV only), weight, blood pressure and other measures deemed appropriate based on the patient s family and medical history. Cognitive function: Assessment and detection of any cognitive function impairment through observation and/or screening. Screening schedule: A schedule of recommended, age-appropriate screenings for the patient to receive in the next five to 10 years based on recommendations from the U.S. Preventive Services Task Force and the patient s health status and screening history. Risk factors: A list of the patient s current risk factors for conditions, including mental health, along with treatment options, risks and benefits. Personalized health advice: Referrals to programs as needed (i.e. tobacco cessation, fall prevention, nutrition, weight loss, etc.) NOT A PHYSICAL EXAM!

IPPE and AWV Clarifications Preventive wellness visits are not annual physical exams Can be performed by a qualified health professional Although specific labs/tests are not included in the IPPE or AWV, tests may be ordered resulting from the exam One-time AAA screening only covered if ordered during an IPPE, not an AWV

IPPE and AWV Clarifications A diagnosis code is required, but not a specific one Confirm an IPPE or AWV hasn t been performed within the past 12 months Separate E/M and medically necessary services can be billed at the same time as the IPPE or AWV with modifier -25 NOT A PHYSICAL

Screening EKG IPPE only Copay/Coinsurance: Yes Ultrasound for AAA IPPE only and if meets certain criteria Cardiovascular Screening - Lipids Every 5 years

Screening Diabetes fasting/non-fasting glucose/gtt Non-diabetics meeting criteria 1-2 times per year depending on previous results Glaucoma Annually if criteria met Copay/Coinsurance: Yes Bone Mass Measurement Every 2 years if criteria met (sooner if medically necessary)

Screening Colorectal Cancer several options Age > 50 yo, timing varies depending on test and risk factors Prostate DRE/PSA Annually beginning the day after 50 th birthday Copay/Coinsurance: PSA No/ DRE Yes Lung Cancer Low dose CT Scan Annually for those eligible Depression Annually

Screening Pap Tests Annually if certain criteria met, otherwise every 2 years Pelvic Exams Annually if certain criteria met, otherwise every 2 years Mammography Female 35-39 yo - one baseline, >40 yo annually

Screening Alcohol Misuse Annual screening Sexually Transmitted Infections Women GC/Chlamydia/Syphilis/Hepatitis B Annually for increased risk, 1-3 times per pregnancy (dz dependant) Men Syphilis only Annually for increased risk HIV Annually for high risk patients, 3 times per pregnancy

Vaccinations Seasonal Influenza Once per season, more if medically necessary Pneumonia Once in a lifetime, more if medically necessary and > 5 yrs since last Hepatitis B Scheduled dosing if at high or intermediate risk

Vaccinations Those NOT covered under Medicare Part B Zoster Vaccine TDaP Though covered under Medicare Part D (medications)

Counseling Diabetes Self-Management Training Individual or group; 10 hrs 1 st year, 2 hrs subsequent years Copay/Coinsurance: Yes Medical Nutrition Therapy Individual or group; 3 hrs 1 st year, 2 hrs subsequent years Diabetes, renal disease/kidney transplant within 3 yrs Intensive Behavioral Therapy for CV Disease Individual; Annually

Counseling Intensive Behavioral Therapy for Obesity Individual; Multiple visits over 6-12 months Tobacco Use Two cessation attempts per year; up to 4 sessions per attempt Alcohol Misuse (Not Dependence) Individual; Four visits per year Sexually Transmitted Infection Prevention Individual; Twice per year

How to code Initial Annual Wellness Visit($172) G0438 Any ICD9 Subsequent Annual Wellness Visit ($111) G0439 Any ICD9 Coding for additional E&M Modifier -25

How To Code

Resources http://www.cms.gov/medicare/prevention/prevntiongen Info http://www.cms.gov/medicare/prevention/prevntiongen Info/Downloads/MPS_QuickReferenceChart_1.pdf http://www.cms.gov/outreach-and-education/medicare- Learning-Network- MLN/MLNProducts/downloads/AWV_chart_ICN905706.p df https://www.cms.gov/medicare/coverage/coveragegeni nfo/downloads/healthriskassessmentscdcfinal.pdf http://www.cms.gov/outreach-and-education/medicare- Learning-Network- MLN/MLNProducts/PreventiveServices.html