Medicare preventative services - ACOFP€¦ · 3/17/2016 3 •“Welcome to Medicare Visit”/...

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Alison Mancuso DO

Assistant Professor & Residency Program Director

Department of Family Medicine

Rowan School of Osteopathic Medicine

April 9, 2016© 2016 Alison Mancuso DO

• Demographics

• Definitions

• “Welcome to Medicare” Visit

• Initial Annual Wellness Visit

• Subsequent Annual Wellness Visit

• Billing and Coding

• Summary

© 2016 Alison Mancuso DO

• At the conclusion of this lecture, participants should be able to:

• 1. Describe types of preventative services now available to

Medicare beneficiaries since ACA implementation

• 2. Describe components of each wellness visit and differentiate

requirements by visit.

• 3. Develop strategies to make outpatient offices more

amenable to performing Medicare preventative services

• 4. Identify proper methods for billing and coding Medicare

Preventative Services.


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• 36 million Medicare enrollees in 2014

• Continues to increase with Baby Boomers

• Preventative Service Utilization- 2014 Report

• 4.8 million beneficiaries have utilized a Wellness Visit in 2014

• 1.6 million in 2012

• 26.3 million beneficiaries have utilized at least on free preventative

service

• 18 million in 2012

• Quality of Care Gap!

• Reimbursements improve with quality indicators…..


All Free Services Annual Wellness Visit

Total Number Percent Number Percent

Nation 36M 26.3M 73.1% 4.79M 14.5%

DE 159K 127K 80.0%

(best)

19.5K 13.1%

MA 907K 711K 78.4% 223K 26.7%

(best)

AK 76.4K 44.5K 58.3%

(worst)

5K 7.6%

(worst)

http://downloads.cms.gov/files/Beneificiaries-Utilizing-Free-Preventive-Services-by-State-YTD-2014.pdf© 2016 Alison Mancuso DO

• The Affordable Care Act (ACA), “Obamacare”

• Legislation that provided coverage for preventative services for Medicare

beneficiaries beginning in 2011

• No out of pocket cost for preventative services

• 100% coverage for United States Preventative Services Task Force

(USPSTF) Grade A/B recommendations and Advisory Committee on

Immunization Practices (ACIP) recommendations

• Caveats:

• New pneumococcal recommendations are covered as of February 2, 2015

• Not all vaccines are covered as a Part B benefit

• Safest bet: Pneumococcal and Influenza vaccines are always part B benefit

• Caution: Tetanus only for exposure as a part B benefit

• Caution: Preventative tetanus, hep b, zostavax are part D!

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/Downloads/MM9051.pdf © 2016 Alison Mancuso DO

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• “Welcome to Medicare Visit”/ Initial Preventative Physical Exam

• Only available in first 12 months of enrollment

• The only time Medicare pays for a “physical”

• Initial Annual Wellness Visit (AWV)

• Covered 11 months after “Welcome to Medicare Visit” or after 12 month

enrollment in Medicare

• Consists of review of history, brief physical exam, counseling

• Subsequent Annual Wellness Visit (AWV)

• Covered 11 months after Initial AWV

• Similar, but less intense


Initial Preventative Physical Exam

(IPPE)


• Initial Preventative Physical Exam (IPPE)

• One time benefit

• Must be completed within first 12 months of Medicare enrollment

• ACA changed from within first 6 months

• No out of pocket cost to patient

• ONLY TIME AAA Ultrasound and Screening EKG are covered!

• These MUST be either done or ordered from the IPPE


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• Review of Comprehensive Health History

• Personal History, Family History, Social History

• Examination

• Vitals: Blood pressure, height, weight, BMI

• Vision Screening

• Screening EKG

• Functional Ability Screen

• Depression Screen


• Counseling• Education on available preventative services

• Vaccines, cancer screenings

• Screening EKG: only covered during this visit

• **AAA screening for patients with family history or MALE patients

age 65-75 with 100 cig smoking history

• Patients leave with written checklist of services recommended

• Education on health concerns or issues found in history and exam portion

of visit


• IPPE: HCPCS Code: G0402

• Work Relative Value Units: 2.43

• National Average Payment: $168.05

• For Comparison: 99214

• Work Relative Value Units: 1.50


• 2015 Medicare Fee Schedule. http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx


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• Non-physician providers bill under their own ID (not “incident-to”)

• Residents are allowed to bill for an IPPE

• Same rules as regular office visits

• Qualifies under Primary Care Exception

• -GE and –GC modifiers

• Coverage is the same no matter what Medicare Advantage Plan

patient has

• Medicare as a secondary will pay for any charges primary does not

• Provider may render other services (ex: pap smear, chronic condition

follow up, etc) by using -25 modifier and appropriate code

• No part of the wellness visit may be used to justify coding of other service



• Not a “physical”, but a “wellness assessment”

• Qualifications

• Not in first 12 months of Medicare

• >11 calendar months since “Welcome To Medicare”/IPPE

• No prior AWVs

• How does staff know who qualifies when scheduling?

• Varies by Medicare contractor

• Online (Form 271) vs Phone

• Always have patient sign ABN!


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Form available from CMS at:

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html© 2016 Alison Mancuso DO

• Visit Components

• History

• Physical Exam

• Counseling

• Pre-visit Patient “Homework”

• Advise patients when they make their appt

• Bring previous medical records, family health history, medication list (or

“brown bag”), provider list

• May provide worksheet for patient to complete prior to visit

• List meds, allergies, providers, family hx, etc

• Health Risk Assessment Questionnaire


• History

• Health Risk Assessment (HRA)

• Survey that patient completes about various areas of health

• Demographics, Mood, Social Support, Pain, Safety, ADLs, Personal Health Assessment, Sleep, Nutrition, Tobacco/Alcohol Use, Exercise, Health Management

• Not one specific HRA is endorsed for AWV

• CDC, AAFP, OFP all have options available

• Ideally have completed prior to physician visit

• Complete Medical & Surgical History

• All illnesses, hospitalizations

• All current and past medical problems

• All surgeries

• All allergies


http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

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• History (cont)

• Complete medication and supplement list

• “brown bag” test might be helpful

• Complete listing of medical specialists and suppliers

• Name and reason for seeing/using

• Family History

• Parents, Siblings, Children


• Completed by patient (survey)

• Should take about 20 minutes for patient to complete (~50 questions)

• Can be done prior to or during AWV

• Needs to be included in chart with office visit note

• Provider must review HRA with patient during visit

• No standard HRA is endorsed by Medicare at this time

• OFP

• CDC

• AAFP


• Demographics• Age, Gender, Race/Ethnicity

• Mood• Depression symptoms

• Interactions with family/friends

• Anxiety/Worrying/Stress

• Social & Emotional Support• Availability

• Pain• Assessment of how much physical pain,

if any

• Tobacco/Alcohol Use

• Exercise/Physical Acitivty

• ADLs• Can they be performed on own

• Safety• Car, Home, Falls

• Personal Health Assessment• Rating of overall health

• Troubling symptoms

• BP/Cholesterol/Sugar

• BMI

• Health Management• Med compliance

• Sleep• Pattern/adequacy

• Nutrition• Fruits/Vegetables/Protein/Junk food


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Full Sample HRAs available at:

http://www.osteopathicfamilyphysician.org/article/S1877-573X(13)00052-X/abstract

(in appendix) or

http://www.cdc.gov/policy/opth/hra/FrameworkForHRA.pdf (look in document appendix)


• Exam Components

• Height, Weight, BMI

• Waist Circumference (if appropriate)

• Blood Pressure

• Cognitive Evaluation: no specific current recommended screening tool

• Ask family/caregivers questions too if present

• Depression Screening: no specific current recommended screening tool

• Could just use “PHQ-2”

• Functional Ability Assessment : no specific current recommended screening

tool

• Hearing, fall assessment, ADLs, IADLs, home safety


• Height/Weight/BMI/Waist Circumference

• If BMI >24.99, counseling must be performed +/- referral to community

resources

• Cognitive Evaluation

• Not necessarily MMSE unless provider feels indication exists

• Simple questions about memory and cognition

• Ask family members/caregivers if present


http://www.osteopathicfamilyphysician.org/article/S1877-573X(13)00052-X/abstract

http://www.cdc.gov/policy/opth/hra/FrameworkForHRA.pdf

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• Depression Screening

• No recommended/required screening tool

• Use any standardized screening tool

• Geriatric Depression Scale

• Beck Depression Inventory

• PHQ-9

• PHQ-2

• If depression is suspected, appropriate treatment/referrals


• Functional Ability Assessment

• No specific screening tool endorsed

• Ask and observe

• How do they do transferring from exam table to standing/walking?

• Do they take care of their own finances, shopping, driving? (IADLs)

• Do they feed/bathe/toilet themselves? (ADLs)

• Have they had any falls?

• Discuss with family/caregivers if present


• Counseling

• Written Screening Schedule (Personalized for patient)

• USPSTF A/B and ACIP Guidelines

• Provide last service date and when due again

• Tip: Use AHRQ ePSS app to easily find what are the A/B

recommendations

• List of Risk Factors/Conditions with recommended interventions

• Problem list with medications/management

• Personalized Health Advice or referral to community based programs if

appropriate

• Weight Management, Smoking Cessation, etc

• “Voluntary” Advanced Care Planning


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BRETT ZZTEST: 66 year old Male


• Checklist: History

Health Risk Assessment Document

List of Current Specialty providers/medical suppliers

Complete past medical and past surgical histories

Complete medication/supplement list

Complete family history (parents, siblings, children)

Complete social history

• Checklist: Exam

Height/Weight/BMI

Waist Circumference (if

applicable)

Blood Pressure

Cognitive Eval

Depression Screen

Functional Assessment


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• Checklist: Counseling

Written schedule of USPSTF/ACIP recommended

screenings/immunizations given to patient and copied for chart

List of risk factors/problems and the current planned interventions

Personalized health advice (smoking cessation/weight management/etc)

and referral to community based programs if applicable

“Voluntary” Advanced Care Planning


• What is not covered

• Screening EKG

• Referral for AAA screening in asymptomatic patients

• Any other physical exam components


• Billing/Coding

• Use code G0438 as your office visit code

• Note: Medicare does not pay for preventative med codes 99381-87

or 99391-97

• Residents may bill for this service using a GC or GE modifier as

appropriate under the primary care exception

• Non-physician providers (NPs/PAs) can bill under their own ID # (instead

of “incident-to” model)


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• Reimbursement for G0438

• RVU 2.43


• Compare to 99214 (RVU 1.50)

• National Average: $108.34

• Source: http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx


• Billing & Coding (Cont)

• You may bill a separate medical service on the same day as the AWV

provided the service is separate and distinct from the AWV

• Example: Managing chronic conditions could be a separate 99212-15

visit with a -25 modifier and separate dx codes

• Note: No part of the AWV may be used to justify coding of other visit

(family hx, medical hx, etc)

• An Advanced Beneficiary Notice (ABN) should be signed by all

Medicare patients prior to receiving a preventative service exam



http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

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• Eligibility Requirements

• Already had an initial AWV

• IAWV was >11 full calendar months prior

• Content

• Updates IAWV


• Requirements

• History

• updated Health Risk Assessment

• Updated medical, surgical histories (may use prior hx if no change)

• Updated list of providers/suppliers

• Updated family history

• Exam

• Weight, Blood Pressure

• Cognitive Evaluation

• Counseling

• Updated written screening schedule

• Updated document with risk factors/treatments/etc

• Updated personalized health advice


• Billing/Coding

• G0439

• Same billing/coding rules as a G0438 (IAWV)

• Reimbursement

• RVU 1.50

• National Average Payment $117.28

• Same RVU as 99214 but reimburses slightly higher

Source: http://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx


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Source: http://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx

Visit Code Work RVU National Payment

G0402 (IPPE) 2.43 $168.05

G0438 (IAWV) 2.43 $173.41

G0439

(SAWV)

1.5 $117.28

99214 1.5 $108.34


Office Staff

• Determining Eligibility

• Electronic Eligibility Response

Transaction Report 271

• Other methods: contact

Medicare service provider

• Proper Billing/Coding

• Using proper HCPCS codes

• ABN usage

Office Policies

• AWVs take longer than usual visits

• Approx 40 minutes in a 1-step

visit

• Could use a 2-step visit with

Nursing staff

• 30 minutes nursing staff

(vitals, history, screening

tools)

• 15-20 minutes provider

(counseling)

• Having patients complete

HRA/History form ahead of time of

visit

• Create EMR or Paper visit template


• Small fraction of Medicare beneficiaries have completed a wellness visit

• What can we do?

• Mention this service during your chronic condition visits to all of your Medicare patients

• Consider posting information in your office for patients to view

• Meaningful Use/PCMH Compliant Electronic Patient Reminders

• Two birds with one stone!

• Replacing just two 99214s per week with an IAWV for 48 weeks of the year would result in over $5600* in additional revenue for the year.

* Using CMS national average payment data


http://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=4&HT=1&CT=1&H1=G0438&H2=99214&H3=G0439&H4=G0402&C=44&M=5

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• For Wellness Visit Templates, Health Risk Assessment Template-

article in Osteopathic Family Physician

• Mancuso AM. “Making the Most of Annual Medicare Wellness Visits.”

Osteopathic Family Physician, 2013-05-01, Volume 5, Issue 3, Pages 102-

115.

• Questions?


• Alison Mancuso DO. Making the Most of the Medicare Annual Wellness Visit. Osteopathic Family Physician.

(2013) 5, 102-115.

• Cara A. Petroski, M.A. and Joseph F. Regan, M.A., M.S.. Use and Knowledge of the New Enrollee “Welcome

toMedicare” Physical Examination Benefit. http://www.cms.gov/Research-Statistics-Data-and-

Systems/Research/HealthCareFinancingReview/downloads/09Springpg71.pdf

• State by State Utilization of Medicare Preventative Service Visits. http://downloads.cms.gov/files/Beneificiaries-

Utilizing-Free-Preventive-Services-by-State-YTD-2014.pdf. Accessed online 8/2015.

• HHS Press Office. More than 16 Million People with Medicare Got Free Preventative Services in 2012.

http://www.hhs.gov/news/press/2012pres/07/20120710a.html. Published July 2012. Accessed online

November 2012.

• Medicare Learning Network. Quick Reference Information: The ABCs of Providing the Annual Wellness Visit.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdf Published January 2012. Accessed online

10/17/2012.


• Patient Protection and Affordable Care Act. Sections 4103-4105. Revised June 2010. http://housedocs.house.gov/energycommerce/ppacacon.pdf. Accessed online October 2012.

•

• Goetzel, RZ; et al. A Framework for patient-centered health risk assessments- providing health promotion and disease prevention services to Medicare beneficiaries. Atlanta, Ga: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. Available at: http://www.cdc.gov/policy/opth/hra/. Accessed October 2012.

• Hughes, Cindy. What You Need to Know About the Medicare Preventive Services Expansion. Family Practice Management. January/February 2011. Accessed online October 2012.

• Cuenca, Arnold E. Making Medicare Wellness Visits Work in Practice. Family Practice Management.Sept/Oct 2012 pp 11-16.

• Centers for Medicare and Medicaid Services Physician Fee Schedule Search. http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx Accessed online February 2015.

• The Henry J Kaiser Family Foundation. Medicare Beneficiaries by State 2012. http://kff.org/medicare/state-indicator/total-medicare-beneficiaries/ Accessed online 10/1/2013.

• Utilization of Medicare Preventative Services by State. http://www.cms.gov/apps/files/preventive-data-chart-first-seven-months-2012.pdf Accessed online 10/1/2013.

• http://downloads.cms.gov/files/Preventive_Services_Utilization_by_State_Jan-Nov_2013.pdfAccessed online 10/15/14.


http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/09Springpg71.pdf

http://downloads.cms.gov/files/Beneificiaries-Utilizing-Free-Preventive-Services-by-State-YTD-2014.pdf

http://www.hhs.gov/news/press/2012pres/07/20120710a.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdf

http://housedocs.house.gov/energycommerce/ppacacon.pdf. Accessed online October 2012

http://www.cdc.gov/policy/opth/hra/

http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

http://kff.org/medicare/state-indicator/total-medicare-beneficiaries/

http://www.cms.gov/apps/files/preventive-data-chart-first-seven-months-2012.pdf Accessed online 10/1/2013

http://downloads.cms.gov/files/Preventive_Services_Utilization_by_State_Jan-Nov_2013.pdf

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