Transcript annual wellness visit - Michigan Academy of Physician Assistants

Medicare Preventive
Services and
Annual Wellness Visit
Tricia Marriott, PA-C, MPAS, DFAAPA
AAPA Director, Reimbursement Advocacy
[email protected]
@TriciaPAC
Disclaimer
•This presentation was current at the time it was
submitted. It does not represent payment or legal
advice.
•Medicare policy changes frequently, so be sure to
keep current by going to www.cms.gov.
•Although every reasonable effort has been made
to assure the accuracy of the information within
these pages, the ultimate responsibility for the
correct submission of claims and response to any
remittance advice lies with the provider of
services.
•The American Medical Association has copyright
and trademark protection of CPT ©.
Medicare Preventive Services:
Terminology
• “Welcome to Medicare” /Initial Preventive
Physical Examination (IPPE)
• Annual Wellness Visit (AWV); Initial and
Subsequent.
• The Initial AWV is NOT the same as the IPPE!
• Personalized Prevention Plan Services (PPPS)
• Health Risk Assessment (HRA)
• Preventive Services
INITIAL PREVENTIVE
PHYSICAL EXAMINATION
Initial Preventive Physical
Examination (IPPE)
• Also known as the “Welcome to
Medicare” Preventive Visit
• One-time visit
• Covered within the first 12 months
of Medicare Part B enrollment
Who Can Provide the IPPE?
• Physician (doctor of medicine or
osteopathy)
• Qualified non-physician practitioner,
which includes a:
–Physician assistant
–Nurse practitioner
–Clinical nurse specialist
“Incident-to” billing
• Does NOT apply to the IPPE
• Claim must be submitted under the NPI of
the rendering provider (the PA).
• Reimbursement will be at 85% of the
physician fee schedule.
How to Code
• Service Code G0402 is used to report the
IPPE
• Location: Typically provided in the office
setting. However, there are location
identifiers for other settings that are allowed.
• Diagnosis Code: there is no specific ICD-9
code. An “appropriate” ICD code should be
chosen. An example of a possible code
would be V70.0. V70.3, V70.9 (General
Medical Examination….)
Payment for G0402-Michigan
Initial preventive physical examination;
face-to-face visit, services limited to
new beneficiary during the first 12
months of Medicare enrollment
• Non-facility $150.85-$162.63
• Facility $121.32-$129.89
Source: CMS Physician Fee schedule Look-up/retrieved February 17,
2013
How Often?
• IPPE (G0402) is a one-time benefit.
• MUST be provided within 12 months of
effective date of Medicare beneficiary’s
Part B coverage.
• The screening EKG, when performed from
an IPPE, is also only covered once in a
beneficiary’s lifetime.
Coinsurance and Deductible
• Effective January 1, 2011, waived for
the IPPE (G0402).
• HOWEVER, the coinsurance and
deductible still applies to the
screening EKG.
The IPPE is a Preventive Visit and
not a Routine Physical Examination
• The IPPE is a dedicated preventive visit where a
beneficiary and their health care provider may
discuss a beneficiary’s health status and
maximize the preventive services that are
available to Medicare beneficiaries
• The IPPE is not a head to toe physical
examination; however there are required
elements. 42CFR 410.16
IPPE Required Elements: History
1. Review of the beneficiary’s medical and social
history.
At a minimum, obtain the following:
• Past medical/surgical history (experiences with illnesses, hospital
stays, operations, allergies, injuries, and treatments);
• Current medications and supplements (including calcium and
vitamins);
• Family history (review of medical events in the
• beneficiary’s family, including diseases that may be hereditary or place
the beneficiary at risk);
• History of alcohol, tobacco, and illicit drug use;
• Diet; and
• Physical activities.
IPPE Required Elements: History
2. Review of the beneficiary’s potential risk
factors for depression and other mood
disorders
Use any appropriate screening instrument for
persons without a current diagnosis of
depression recognized by national professional
medical organizations to obtain current or past
experiences with depression or other mood
disorders.
IPPE Required Elements: History
3. Review of the beneficiary’s functional ability
and level of safety
Use any appropriate screening questions or
standardized questionnaires recognized by
national professional medical organizations to
review, at a minimum, the following areas:
• Hearing impairment,
• Activities of daily living,
• Falls risk, and
• Home safety.
IPPE Required Elements: Exam
4. An examination
Obtain the following:
• Height, weight, and blood pressure;
• Visual acuity screen;
• Measurement of body mass index; and
• Other factors deemed appropriate based on the
• beneficiary’s medical and social history and
current clinical standards.
IPPE Required Elements: Exam
5. End-of-life planning
End-of-life planning is a required service, upon the
beneficiary’s consent. End-of-life planning is verbal
or written information provided to the beneficiary
regarding:
• The beneficiary’s ability to prepare an advance directive
in the case that an injury or illness causes the
beneficiary to be unable to make health care decisions,
and
• Whether or not the physician is willing to follow the
beneficiary’s wishes as expressed in the advance
directive.
IPPE Required Elements:
Counseling
6. Education, counseling, and referral based on
the previous five components
Based on the results of the review and
evaluation services provided in the previous five
components, provide education, counseling, and
referral as appropriate.
IPPE Required Elements:
Counseling
7. Education, counseling, and referral for other
preventive services
Includes a brief written plan, such as a
checklist, to be given to the beneficiary for
obtaining a screening electrocardiogram (EKG),
as appropriate, and the appropriate screenings
and other preventive services that are covered
as separate Medicare Part B benefits.
Resources
Quick Reference Information: The ABCs of Providing the Initial
Preventive Physical Examination Medicare Learning
Network® (MLN) Products
http://www.CMS.gov/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf
The Guide to Medicare Preventive Services, Chapter 1
http://www.CMS.gov/MLNProducts/downloads/mps_guide_web061305.pdf
Claims Processing Manual Pub. 100-04,
Chapter 18, Section 80
http://www.cms.gov/manuals/downloads/clm104c18.pdf
Chapter 12, Section 30.6.1.1
http://www.cms.gov/manuals/downloads/clm104c12.pdf .
ANNUAL WELLNESS VISIT
Annual Wellness Visit (AWV)
• Beneficiary has had Part B for more than 12
months.
• Available once every 12 months.
• If beneficiary had an IPPE/Welcome to Medicare
visit, then they will be eligible for AWV 12
months following the IPPE.
Who Can Provide the AWV?
A “health professional” meaning:
–
–
–
–
–
Physician
Physician assistant
Nurse practitioner
Clinical nurse specialist
Medical professional (including health educator, RD,
nutrition professional, or other licensed practitioner) or a
team of such medical professionals, working under the
direct supervision of a physician.
*Note: includes
NPP!
The AWV is a Preventive Visit and
not a Routine Physical Examination
• The AWV is a yearly dedicated preventive visit
where a beneficiary and their health care
provider may discuss a beneficiary’s health
status and maximize the preventive services that
are available to Medicare beneficiaries
• Like IPPE, the AWV is not a head to toe physical
examination
“Incident-to” Billing
• Does NOT apply to the AWV
• Claim must be submitted under the NPI of the
rendering provider (the PA).
• Reimbursement will be at 85% of the physician
fee schedule
First Annual Wellness Visit
•
•
•
•
Health risk assessment
Medical/family history
List of current providers/suppliers
blood pressure, height, weight, and other routine
measurements
• Detection of any cognitive impairment
• Review potential (risk factors) for depression, functional
ability, and level of safety
Establishment of:
• Written screening schedule (such as a checklist) for the next
5-10 years
• List of risk factors and conditions where interventions
recommended
• Personalized health advice and referrals for health education
and preventive counseling
Subsequent Annual Wellness Visit
•
•
•
•
Updated health risk assessment
Update of medical/family history
Update of list of current providers/suppliers
blood pressure, weight, and other routine
measurements
Update to:
• Written screening schedule
• List of risk factors and conditions where
interventions are recommended
• Personalized health advice and referrals for
health education and preventive counseling
Health Risk Assessment (HRA)
• Collects self-reported information known to the
beneficiary
• Can be administered by beneficiary or health
professional before, or as part of, the annual wellness
visit
• Takes no more than 20 minutes to complete
• Addresses the following topics:
Demographic data
Self assessment of health status
Psychosocial risks
Behavioral risks
Activities of daily living and instrumental activities of
daily living
How to Code
Service Codes:
• G0438 (Annual wellness visit, including
Personalized Prevention Plan Service (PPPS),
first visit), and
• G0439 (Annual wellness visit, including PPPS,
subsequent visit).
 Diagnosis Code: there is no specific ICD-9 code.
An “appropriate” ICD code should be chosen.
An example of a possible code would be V70.0.
V70.3, V70.9 (General Medical Examination….)
Payment rates-Michigan
• G0438 (AWV, initial visit)
Medicare Non-facility Payment $160.59-$173.42
• G0439 (AWV, subsequent visit)
Medicare Non-facility Payment $106.50-$114.27
Source: CMS Physician Fee schedule Look-up/retrieved February 17, 2013
How Often?
• First Visit (G0438)-once in a lifetime
• Subsequent visit (G0439)-annually after 11 full
months have passed since the last AWV
Coinsurance and Deductible
• Effective for dates of services on or after
January 1, 2011
• Copayment or coinsurance and the Medicare
Part B deductible are waived for the AWV
(G0438 and G0439)
Resources
MLN Products Quick Reference Information: The
ABCs of Providing the Annual Wellness Visit
http://www.CMS.gov/MLNProducts/downloads/A
WV_Chart_ICN905706.pdf
MM7079: Annual Wellness Visit (AWV), Including
Personalized Prevention Plan Services (PPPS)
http://www.cms.gov/MLNMattersArticles/downloa
ds/MM7079.pdf
The Guide to Medicare Preventive Services,
Chapter 4
http://www.CMS.gov/MLNProducts/downloads/m
ps_guide_web-061305.pdf
More Resources
• For Health Professionals:
MLNMatters Article
http://www.cms.gov/MLNMattersArticles/Downloads/MM7079.pdf
A Framework for Patient-Centered Health Risk Assessments
(Centers for Disease Control and Prevention)
http://www.cdc.gov/policy/opth/hra
• For Beneficiaries:
General Preventive Services Resources
http://www.medicare.gov/navigation/manage-yourhealth/preventive-services/preventive-service-overview.aspx
Your Guide to Medicare’s Preventive Services
http://www.medicare.gov/Publications/Pubs/pdf/10110.pdf
Covered Preventive
Services
Wait…..
What?
Covered Preventive Services
IPPE and AWV are just part of the range of
preventive services covered by Medicare.
Medicare Part B
Preventive Services
• Initial Preventive Physical Examination (IPPE)
• Intensive Behavioral Therapy (IBT) for Obesity (effective November
29, 2011)
.
• Bone Mass Measurements
• Medical Nutrition Therapy (MNT)
• Cardiovascular Screening Blood Tests
Prostate Cancer
Screening
• Colorectal Cancer Screening Seasonal Influenza, Pneumococcal,
and Hepatitis B Vaccinations and their Administration
• Counseling to Prevent Tobacco Use for Asymptomatic Patients
Screening and Behavioral Counseling Interventions in Primary
Care to Reduce Alcohol Misuse (effective October 14, 2011)
• Diabetes Screening Tests
• Screening for Depression in Adults (effective October 14, 2011)
Continued…
•
•
•
•
•
•
Diabetes Self-Management Training (DSMT)
Screening Mammography
Glaucoma Screening
Screening Pap Tests and Pelvic Examination
Human Immunodeficiency Virus (HIV) Screening
Sexually Transmitted Infections (STIs) Screening and
High Intensity Behavioral Counseling (HIBC) to Prevent
STIs (effective November 8, 2011)
• IBT for Cardiovascular Disease (effective November 8,
2011) Ultrasound Screening for Abdominal Aortic
Aneurysm (AAA)
Covered Services
• The Guide to Medicare Preventive Services
http://www.CMS.gov/MLNProducts/downloads/m
ps_guide_web-061305.pdf
• MLN Preventive Services Products Page
http://www.cms.gov/MLNProducts/35_Preventive
Services.asp
• The CMS Prevention Website
http://www.cms.gov/PrevntionGenInfo
Take Home
• PAs are eligible providers; Service must be
billed under the PA.
• There are great resources and job aids/charts to
guide both the provider and the patient through
the prevention services.
• IDEAL issue for your local health fair:
“Ask me about: Medicare’s Preventive Services”.
“Have you had your screenings?”
There’s an APP!
• Multiple platforms and devices supported
• From AHRQ-browse U.S. Preventive Services
Task Force (USPSTF) recommendations on the
web or on your PDA or mobile device
• http://epss.ahrq.gov/PDA/index.jsp
AAPA Website
• Summary that includes links to Medicare
Resources and tables.
• http://www.aapa.org/uploadedFiles/content/Your
_PA_Practice/Reimbursement/Resource_Items/
Medicare_Preventive_Services_2013.pdf
Member Log-in required.
Bill one AWV and your CD is paid for!
• Wellness Visits pay BIG dollars with minimum physician time- but only if you
have the right workflow tools. Medicare patients will continue to take
advantage of these important Annual Wellness Visits now that the health
reform law is officially here to stay.
• Ensure that your wellness visits are quick and efficient while complying with
all Medicare requirements with the Annual Wellness Visit Encounter
Tools.
• This complete set of 3 comprehensive AWV encounter forms meets both
CMS and CDC guidelines, so you're guaranteed a set of forms that are
100% up-to-date for use in 2013 and beyond.
This single CD includes:
•
Initial AWV patient form (View a Sample Page)
•
Subsequent AWV patient form
•
Health Risk Assessment (HRA) form - Newest element of the AWV
•
The Annual Wellness Visit Encounter Tools help you:
•
Save time by having pre-developed forms that are comprehensive and require no additional elements
•
Optimize your AWV workflow to minimize physician time by having HRA forms your staff can use to prepare
patients before they arrive
•
•
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