Medicare Annual Wellness Visits Presented By Mark Vaughan, M.D., Auburn Medical Group &

Kathryn Melton, CPC, CRC, Sutter Independent Physicians

Goals

• To explain why Annual Wellness Visits are important for Quality Intervention

• To describe the types of Annual Wellness Visits

and their components

• To discuss how Annual Wellness Visits are related to chronic disease management

Every 29 minutes an older adult dies from a fall. A senior that falls and breaks their hip will have a 20% chance of death and a 30% chance of permanent disability within one year. Less than half who fell in the previous year talked to their healthcare provider about it.

Source: http://www.cdc.gov/

The rate of suicide among older adults is higher than that for any other age group.* 20 percent of those who commit suicide visited their primary care physician on the same day and 40 percent within one week of the suicide.* An older adult with diabetes and depression has a 78% higher risk of mortality.**

*Source: http://www.nimh.nih.gov/ **Journal of American Geriatrics Society 62:1017-1022, 2014

Someone in the United States develops Alzheimer’s every 67 seconds. Nearly one in every five Medicare dollars is spent on people with Alzheimer’s and other dementias. In 2050, it will be one in every three dollars. Approximately 40 percent of Alzheimer’s and dementia caregivers suffer from depression. Source: http://www.alz.org/

What We Need to Understand: To reduce the risk of disability, institutionalization, avoidable health care costs, and premature deaths, the health care system must focus on maintaining seniors’ independence and quality of life. The Annual Wellness Visit (AWV) is a vehicle to

•Perform a comprehensive health assessment •Create/update a 5-10 year preventive schedule based on the patient’s needs.

What We Think Patients Want to Know

Give it to me straight, Doc. How long do I have to ignore your advice?

AWV = Improved Communication

• What concerns the 65 y.o. Medicare patient differs from concerns of the 85 y.o. patient – Younger Medicare patients want to know how

to stay active – Older Medicare patients want to know how to

remain independent • Patients want to be heard - the AWV is an

opportunity for patient and clinician dialogue

Why is AWV Important

• The AWV is an opportunity to: – Perform a comprehensive health risk

assessment – Re-evaluate/recapture existing chronic

conditions for risk adjustment reporting – Screen for early identification of new

conditions – Address gaps in care including P4P measures – Connect with patients and prepare a

written, multi-year, personal plan

AWV does not = Physical Exam

• The AWV = information-gathering, assessment, counseling

• The Physical Exam = examination of vital

signs, organs, body systems

• The Annual Wellness Visit is not meant to replace the annual physical

The Quality Imperative

Inadequate documentation and coding: • Compromises patient safety

• Reduces ability to identify and provide

appropriate care management services

• Hinders care team coordination

• Contributes to delivery of ineffective care

Preparing for the AWV Visit

• Holistic Chart Review

• To understand what conditions the patient has or may have

• Comprehensive Assessment • To support comprehensive reporting of HCC-

weighted conditions

Understanding Medicare AWVs Code & Rate

Benefit Medicare coverage history

Frequency limitations

Patient Financial Responsibility

G0402 $168.07

Initial Preventative Physical Exam (IPPE), AKA Welcome to Medicare Visit

Service provided during the first 12 months of coverage

Cannot have had a previous IPPE by any provider

Waived

G0438 $173.44

Initial Annual Wellness Exam (AWV)

Coverage began more than 12 months prior to date of visit

12 months have passed since IPPE or the patient has not had a IPPE

Waived

G0439 $117.29

Subsequent Annual Wellness Visit (AWV)

Coverage began more than 12 months prior to date of visit

12 months have passed since last AWV for FFS; Calendar year for Medicare Advantage

Waived

Source: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html

What’s Included in the IPPE? (Welcome to Medicare Visit – G0402)

1. Review of the patient’s medical and social history

2. Review of patient’s potential risk factors for depression and other mood disorders

3. Review of patient’s functional ability and level of safety

4. An examination

5. End of life planning

6. Education, counseling, and referral based on the previous five components

7. Education, counseling, and referral for other preventative services

What’s Included in the Initial AWV? (G0438)

1. Health Risk Assessment 2. Establishment of the patient’s medical/family

history 3. Review of the patient’s potential risk factors for

depression, including current or past experiences with depression or other mood disorders

4. Review of the patient’s functional ability and level of safety

What’s Included in the Subsequent AWV? (G0439)

1. Update of health assessment 2. Update of patient’s medical/family history 3. Update of the list of current providers and suppliers 4. Assessment for cognitive impairment 5. Update of written screening schedule and Personal

Prevention Plan of Service 6. Update of risk factors and conditions for which care is

recommended or underway for the patient 7. Furnishing of personalized health advice and referrals,

as appropriate, to health education or preventative counseling services/programs

What Does the Clinician Really Need To Do?

1. Get the forms that have all the required questions (ADLs, PHQ-2 depression screen, Specialists list, Supplier list, End of life discussion documentation)

2. Ask about falls and do a basic test…or two

3. Do a Mini-Cognitive Screening

4. Provide the patient with a written care plan

Medical Assistants (MAs) are key members of the total care team. Medical Assistants may not make any clinical assessment of a patient’s condition, presentation or complaint, even if asked to do so by a patient or clinician. Medical Assistants may not interpret for patients or clinicians, in any manner, any test result or other clinical finding. Medical Assistants must be formally trained and demonstrate competency to perform any clinical tasks assigned to them. The Medical Assistant may NOT perform the following required tasks of the Annual Wellness Visits:

•Mini-mental status examination (MMSE) or the Mini-Cog. •Score the PHQ-2 or PHQ-9. •Fall risk tests that require observation and evaluation of gait, postural stability, stride length and sway (e.g., 30 second UP and Down Test, 4 position balance test).

What Can the Medical Assistant Do?

Health Risk Assessment Form •Can be completed by patient prior to visit or with MA •Includes PHQ-2 depression screen

Scoring the PHQ 9 •Total Score rates the depression severity, from 0 – 27 •General question assesses functional impairment, “How difficult have these problems made it for you do your work, take care of things at home or get along with other people?”

Rate severity of MDD based on PHQ 9 or symptoms and functional impairment

Severity PHQ 9 Score Symptom and Functional Impairment Mild 5 – 9 5 – 6 sx of mild severity (including mood) and function mildly impaired or nl but w/ substantial and unusual effort Moderate 10 – 14 Moderately Severe 15 – 19 Severe 20 – 27 most sx present & severe and function disabled or psychotic features

UCLA also recommends the “30 second Up and Down Test” plus the “4 position balance test”

Fall Risk Assessment

3-word recall plus the clock drawing

Cognitive Function Assessment

Do Annual Wellness Visits Affect HCC Chronic Disease Documentation?

Annual Wellness Visits HCC Capture Rates

Poor Mrs. Jones

• Interactive game that helps us think about potential diagnoses based on existing conditions/problem list.

• What diagnoses are probable based on Mrs. Jones’ symptoms?

• Let’s take a look!

26

Meet Poor Mrs. Jones

• Osteoporosis • Vitamin D deficiency • Hypercalcemia • Low back pain

What other health conditions might

she also have? 27

During the Annual Wellness Visit, you review Poor Mrs. Jones’ chart and notice she has:

Potential HCC Diagnoses

• Lumbar compression fracture • Hyperparathyroidism

HCC score: 0.70

28

Poor Mrs. Jones’ Sister Has:

• CAD • Hypertension • Palpitations • Leg edema

29

What else might she also have?

Potential HCC Diagnoses

• History of MI • Chronic kidney disease • Paroxysmal atrial fibrillation • Chronic Diastolic CHF

HCC score: 0.95

30

Poor Mrs. Jones’ niece has:

• Hepatitis • Ascites • Kidney disease • Orthostatic hypotension

What else might she have?

31

Potential HCC Diagnosis

• Primary Biliary Cirrhosis • Portal Hypertension • Chronic Kidney Disease • Autonomic dysfunction

HCC score 2.16

32

Poor Mrs. Jones’ brother has:

• Joint pains/arthritis • Weight loss • Chronic steroid dependency • Acute low back pain

What else might he have?

33

Potential HCC Diagnoses

• Rheumatoid arthritis • Protein calorie malnutrition • Immunocompromised state • Thoracic compression fracture

HCC Score: 2.56

34

Poor Mrs. Jones’ cousin has:

• History of breast cancer, on Tamoxifen

• Anxiety and Depression • CAD • Neuropathy

What else might she have?

35

Potential HCC Diagnoses

• Breast cancer • Major depressive disorder • Chemo-induced cardiomyopathy • Chemo-induced toxic neuropathy

HCC Score: 3.57

36

Seeing the Entirety of the Patient

“What you seem to be suffering from

is longevity.”

Medicare AWV toolkit includes: Coding tools AWV elements grid Medicare AWV form Screening tools w/ICD-10 tips

•Timed Get Up & Go Test •Mini Cog •Depression •Fall Risk Checklist

Personalized Prevention Plan of Service (PPPS) Phone call Scripts/letters Patient Handouts

•AWV brochure •AWV patient questionnaire

To receive a free complete AWV toolkit contact: Kathryn Melton, CPC, CRC (916) 731-7817 meltonk@sutterhealth.org Sutter Independent Physicians

Cognitive Impairment Screening tool - Example 1

Cognitive Impairment Screening tool

Example 2

Functional Ability safety screenings for Fall Risk Prevention: Timed Get up and Go Test Fall Risk Assessments & Checklist

Personalized Prevention Plan of Service (PPPS)

Provide a written screening schedule for the patient Checklist for the next 5 years such as Preventive Services/Screenings and Immunizations due as appropriate* List of risk factors and conditions for which interventions are recommended or underway Provide specific topic handouts on your recommendations •See sample of “Healthy Living for Adults” handout

*based on recommendations of the US Preventative Services Task Force (USPSTF) & the Advisory Committee on Immunization Practices (ACIP)

Scheduling the AWV tool: Call Scripts- Identify what type of AWV appointment New to Medicare? Initial or Subsequent

Briefly explains what is included in the visit to the patient

Patient Letter-

•See example

A few things to keep in mind: Mandatory component: Discussing end-of- life planning must be offered to the beneficiary. If the beneficiary does not want to discuss, document this in the patient's medical record that end-of-life planning was offered but refused. Does the patient have to fill out a health risk assessment questionnaire before seeing the provider, or can these be part of the "screening" when the medical assistant is taking the information? This is an option, but not a requirement. It is up to the provider.

AWV is a win-win for all involved!

Patients are better educated Quality of healthcare is improved Healthcare costs are decreased Revenue is increased for providers and managed care

organizations

SIP wants physicians to be successful!

We encourage you to take time to plan your practices for the Annual Wellness Program (AWV)

Coding questions for Medicare Annual Wellness Visit (AWV) or need additional resources? SIP is here to help! Kathryn Melton, CPC, CRC (916) 731-7817 meltonk@sutterhealth.org