“The Medicare Wellness Visit” Jessica L. Masser, DO
Medicare Wellness Visit
Jessica Masser, MS, DO, MSMedEd, FAAFP, FACOFP January 25, 2018
Outline
• What are they? • Why we do them? – Patient care – Quality markers • Components • Suggested work flow • Billing and coding
Wellness Exam
• For every adult periodically – During regular visits • Medicare “brand” – NO COPAY COLLECTED – Done all at one visit • Other insurances including Medicaid cover
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 1 “The Medicare Wellness Visit” Jessica L. Masser, DO
Exam Types
• Welcome to Medicare – Within first 12 months of enrollment • Initial Annual Wellness Visit – If Welcome visit not done • Subsequent Annual Wellness Visit – 12 months after first AWV
Wellness Exam Difficulties
•Takes time – Comprehensive exam • Multiple steps • Specific components must be completed – Integration at problem-oriented visits • Not paid for additional work •Solution – Allowed prevention to be moved to a single visit, with pay
Wellness Exam Purpose
• Screening – Detect current problems or risk for future •History • Labs and radiology • Minimal physical exam •Education – Recommendations – Wellness behaviors • Chemoprophylaxis – Immunizations, etc
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 2 “The Medicare Wellness Visit” Jessica L. Masser, DO
Quality Measure
• Used as a guide for quality care provided to the elderly – Increase per person revenue – Increase overall score • Ex: STARS program
When, Where and Who
•Timing per year is based on each individual carrier –Highmark • Calendar year –UPMC •Yearly (12 months apart)
When, Where and Who
•Setting –Office –SNF – Personal Care –Home – Hospital – in theory
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 3 “The Medicare Wellness Visit” Jessica L. Masser, DO
When, Where and Who
•Any provider – Physician – CRNP –PA-C – PharmD –Nurses –Staff
History Requirements
• Past medical history •Surgeries • Current Meds and supplements • Family History • Social History – Alcohol, tobacco and illicit drug use •Diet • Physical Activity
NOTE: if these have already been done recently it is only necessary to “review” or say no change
History Requirements
• Depression Screen – Instrument recognized nationally – Easiest is to use 2 standard questions • In the last 2 months have you frequently: – Been sad or depressed – Had less interest in doing things you like to do • If yes to either then a more thorough history is necessary – No specific guidelines are provided
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 4 “The Medicare Wellness Visit” Jessica L. Masser, DO
History Requirements
• “Review of functional ability and level of safety” – “Use direct observation” – “Any screening designed for this purpose and recognized by national professional organizations” • Assess – Hearing impairment – ADLs/IADLs – Fall risk – Home safety ? A bit ambiguous ?
History Requirements
• Hearing impairment – Do you have trouble hearing or have others said so? • If positive a more complete history is needed – Hearing test is required at Welcome & Initial • Activities of daily living – Asking if there are any difficulties with ADLs & IADLs • If any positives a full ADL/IADL inventory is necessary
History Requirements
• Fall Risk – In the last year, history of previous falls and worry about falls is enough • Incontinence inquiry • Home Safety Review – Ask patient and family, if present, about unsafe conditions • If positive then should provide a home safety checklist
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 5 “The Medicare Wellness Visit” Jessica L. Masser, DO
History Requirements
• Cognitive Impairment Screen – Ask about trouble with memory or if others have concerns – If family is with patient, best to ask them also • Listing of all other providers and suppliers
History Requirements
• Determine what preventive tests and immunizations have already been done and when – Prepare prior to visit • Will need to plan for completion
Physical Exam Requirements
•Vitals – Weight – Height –BMI – Blood pressure • Vision Exam • Hearing Exam • Basic Gait Exam –“Get Up and Go” • Basic Cognitive Impairment Screen No need to do anything else and best not to
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 6 “The Medicare Wellness Visit” Jessica L. Masser, DO
Physical Exam Requirements
• Vision Exam – Skip if documented recent eye exam – Snellen • Hearing test • Basic Gait Exam – Get up and go test • Stand from an armed chair, walk 10 ft, turn around, walk back and sit down • Fall risk is generally significant if > 20 sec • Cognitive Impairment Screen – No specific test is dictated – A general “feel” from talking to the patient • If positive a more thorough evaluation is needed
Not Required !!
• Best not to do – Chief Complaint/Problem – ROS (other than items mentioned) – Full PE – Actual giving the immunizations or ordering the labs or radiology • Clinical decision • Patient wants it then & understands the cost • Provider knows they may not get another opportunity
Testing Requirements
• Must advise patient about all indicated preventive items – Paid for by Medicare – Advised by USPSTF – Advisory Committee on Immunization Practices (ACIP) – Due in the next 5-10 years • Procedures, Radiography, Labs, Immunizations, Counseling
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 7 “The Medicare Wellness Visit” Jessica L. Masser, DO
EKG
• Not required, but is a covered option once – Only with Initial Exam (Welcome exam) • Deductible and Co-pay apply
Other Requirements
• Education/Advice – Establishment of a list of risk factors/conditions • Preventive interventions should be recommended •Examples – Mental health – Weight loss – Physical activity –Smoking – Fall prevention
End of Life/Advance Directives
• Discussion or Review not required • Wise to briefly screen •Simply – “If you haven’t done the paperwork for Health Care Power of Attorney and Living Will, I highly recommend you do. We have the forms” • https://www.acba.org/public/livingwill
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 8 “The Medicare Wellness Visit” Jessica L. Masser, DO
Requirement
• All recommendations must be in WRITING – “personalized health advice and referral” • Must provide documentation that all requirements were done
Medicare does audits and gives penalties if incomplete exam was done
“Hidden” Costs
• Some recommended interventions are NOT free – Deductible/Co-pay • Immunizations • Intervention during screening – Polypectomy during colonoscopy • Labs • Diabetes self-management • EKG • Glaucoma Screening
How to Keys
• Scheduling the appointment – Do at time of a problem visit – Encourage patients to make appointment • Office ads, flyers, letters • Incentives from the insurance – Gift cards, etc. • Highly suggested option ? – Book 2 appointment slots
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 9 “The Medicare Wellness Visit” Jessica L. Masser, DO
How to Keys
• 2 forms required – can be electronic – Patient History Questionnaire – Patient Education Form • Lists all advised interventions for next 5-10 years • Can be helpful: – Provider Checklist • To document a summary that all requirements were met • All documentation needs to be in the record –Scanned into EMR –Placed in the patient file
How to Keys
• Prepare staff – Team event • Prepare patient before the exam room – State at the time of scheduling – Provide education letter • Purpose and problems not covered – Staff state, “you are here today for your MWV” • Prepare physician – Know Health Maintenance like an expert – Know before entering exam room that it is MWV
Game Time
•Front desk – Schedule patient • 30 minutes (?) – do not overlap • Clearly state Medicare Wellness Visit • Explain NO COPAY – FOR THE VISIT ONLY • Prep for no problems – If a problem is identified then what?
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 10 “The Medicare Wellness Visit” Jessica L. Masser, DO
Game Time
•Triage –Vitals – Visual Acuity • Or documentation of recent eye exam – Hearing test – History questionnaire – Patient advised of purpose & scope of visit – Have form, template, checklist, POA papers all ready – Perform “get up and go” test
Game Time
•Physician – Confirm agenda – Complete or update FH and SH – Review Med List – Review questionnaire – Review vitals – Perform cognitive impairment screening –Option • Very brief cardiac and lung exam • If increased skin cancer risk, consider skin exam – Complete the Patient Education checklist – Finalize what specifics will be done today
Game Time
•Physician – Diagnostic Codes • Z00.00 – Billing Codes • Welcome – G0402 • Initial – G0438 • Subsequent – G0439
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 11 “The Medicare Wellness Visit” Jessica L. Masser, DO
But They’re Sick
• Two visits can be billed but watch – Separate identifiable condition/problem – All components for E&M level needed – Cannot bill two visits for refills, “routine” monitoring of existing condition, ordering labs • Try to judge based on when the condition was found – Identified at check-in – Identified during triage/rooming – Identified during provider portion
But They’re Sick
• Try to judge based on when the condition was found – Identified at check-in • Do NOT do AWV – convert to regular visit – Identified during triage/rooming • Could be possible to do 2 visits – Identified during provider portion • Likely two visits • Does increase audit potential for frequent two visit bills
Wrap Up
• Covered service through all Medicare carriers • Beneficial to you and the patient • Specific items required – Gray zones about some requirements • Have a process to make it a habit • Ensure you are coding correctly • Remember – these are intended to provide good quality patient care
POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 12 “The Medicare Wellness Visit” Jessica L. Masser, DO
References
• Medicare.gov. https://www.medicare.gov/coverage/preventive-visit- and-yearly-wellness-exams.html, accessed last 1/15/2018. • MedicareInteractive.gov. https://www.medicareinteractive.org/get- answers/medicare-covered-services/preventive-care-services/annual- wellness-visit, accessed last 1/15/2018. • CMS.gov. https://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network- MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf, accessed last 1/15/2018.
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