Medicare Wellness Visits for FQHCs

Medicare AWV Questions What are the benefits of providing the wellness visits? What is the difference in the visits? Who can perform the wellness visits? If the visit is done at a FQHC does a provider (MD, DO, PA, NP, and CNM) have to see the patient? If the AWV provider is a NP or PA will the visit count toward ACO assignment?

1. IPPE & Annual Wellness Visits Benefits No cost to patient!! Generates revenue for the health center Ensures  ACO attribution if billed by MD/DO Opportunity to address gaps in care Opportunity to meet GPRO measures (ex., falls assessment) Could help improve accuracy of HCC coding Potential additional benefits: Keep patients healthy Enhances quality of care Improves patient engagement Promote preventive health Help to build retention

2. The Initial Preventative Physical Exam IPPE (“Welcome to Medicare” Preventive Visit) The patient must receive this service within the first 12 months after the effective date of their Medicare Part B coverage. One-time benefit. Consists of the following: Review the patient’s medical and social history; Review potential risk factors for depression and other mood disorders; Review functional ability and level of safety; Measurement of height, weight, body mass index (BMI), and visual acuity screening. End-of-life planning (upon agreement of the individual); Education, counseling and referral based on the review of previous 5 components; and Education, counseling and referral for other preventive services, including a brief written plan such as a checklist. Who can perform an Initial Preventive Physical Exam? Medicare Part B covers an Initial Preventive Physical Exam if it is furnished by a: Physician (doctor of medicine or osteopathic medicine), or Other qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist) 2. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1338.pdf MLN Matters® Number: SE1338 Re-issued

2. 1st AWV and Subsequent AWVs The first AWV includes the following elements: A health risk assessment; Establishment of a current list of provider and suppliers; Review of medical and family history; Measurement of height, weight, BMI, and blood pressure; Review of potential risk factors for depression and other mood disorders; Review of functional ability and level of safety; Detection of any cognitive impairment the patient may have; Establishment of a written screening schedule (such as a checklist); Establishment of a list of risk factors; and Provision of personalized health advice and referral to appropriate health education or other preventive services. Subsequent AWVs include the following elements: Review of updated health risk assessment; Update of list of current providers and suppliers; Update medical and family history; Measurement of weight and blood pressure; Detection of cognitive impairment the patient may have; Update of the written screening schedule (such as a checklist); Update of the list of risk factors; and Provision of personalized health advice and referral to appropriate health education or other preventive services. 2. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1338.pdf MLN Matters® Number: SE1338 Re-issued

3. Who Can Perform the AWV? Who can perform the Annual Wellness Visit? Medicare Part B covers the Annual Wellness Visit (AWV) if it is furnished by the following: 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). CMS is not assigning particular tasks or restrictions for specific members of the team. We believe it is better for the supervising physician to assign specific tasks to qualified team members (as long as they are licensed in the State and working within their state’s scope of practice). This approach gives the physician and the team the flexibility needed to address the beneficiary’s particular needs on a particular day. It also empowers the physician to determine whether specific medical professionals who will be working on his or her wellness team are needed on a particular day. The physician is able to determine the coordination of various team members during the AWV. Definitions: Levels of Supervision General Supervision - means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. Direct Supervision - in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean the physician must be present in the room when the procedure is performed. Personal Supervision - means a physician must be in attendance in the room during the performance of the procedure. https://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/8EEL736213?open Medicare area claims processor 3. Frequently Asked Questions from the March 28, 2012 Medicare Preventive Services National Provider Call: The Initial Preventive Physical Exam and the Annual Wellness Visit https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/IPPE-AWV-FAQs.pdf

4. Does a Provider have to see the patient? At a FQHC, Yes Billable Visit- Face-to-face encounter between the patient and a Physician, Physician Assistant (PA), Nurse Practitioner (NP), Certified Nurse Midwife (CNM), Visiting Nurse, Clinical Psychologist (CP) or Clinical Social Worker (CSW) during which a FQHC service is rendered. 4. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf Specific Payment Codes for the Federally Qualified Health Center December 2016 Prospective Payment System (FQHC PPS) (Rev. 12-22-16) From: Melanie Watkins (NCCHCA) [mailto:watkinsm@ncchca.org] Sent: Tuesday, July 18, 2017 9:29 AM To: CMS FQHC-PPS <FQHC-PPS@cms.hhs.gov> Subject: Medicare Annual Wellness Visit   If a RN performs the annual wellness visit, is it necessary for the physician to see the patient to bill for the service (G0438 or G0439)?

5. Can NPs & PAs perform the AWV for FQHC patients? Yes ACO professional means an individual who is Medicare-enrolled and bills for items and services furnished to Medicare fee-for-service beneficiaries under a Medicare billing number assigned to the TIN of an ACO participant in accordance with applicable Medicare regulations and who is either of the following: (1) A physician legally authorized to practice medicine and surgery by the State in which he or she performs such function or action. (2) A practitioner who is one of the following: (i) A physician assistant (as defined at § 410.74(a)(2) of this chapter). (ii) A nurse practitioner (as defined at § 410.75(b) of this chapter). (iii) A clinical nurse specialist (as defined at § 410.76(b) of this chapter). This is where we have to switch hats between a FQHC and the ACO. In the MSSP regulation ACO professional is defined as … 5. Title 42 - Public Health Chapter IV - CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) Subchapter B - MEDICARE PROGRAM (CONTINUED)Part 425 - MEDICARE SHARED SAVINGS PROGRAMSubpart A - General Provisions Section § 425.20 - Definitions. https://www.gpo.gov/fdsys/pkg/CFR-2015-title42-vol3/pdf/CFR-2015-title42-vol3-sec425-20.pdf

5. If the AWV provider is a NP or PA will the visit count toward ACO assignment? If the AWV is the only primary care service a patient receives in a year and the AWV was provided by a NP or PA, No it will not count toward the patient being assigned to the health center. PRE-STEP Assignable beneficiary means a Medicare fee-for-service beneficiary who receives at least one primary care service with a date of service during a specified 12-month assignment window from a Medicare-enrolled physician who is a primary care physician or who has one of the specialty designations included in § 425.402(c). The first step assigns a beneficiary to an ACO if he or she receives a plurality of primary care services from primary care practitioners (i.e., primary care physicians, nurse practitioners, clinical nurse specialists, physician assistants, or ACO professionals providing services at a FQHC/RHC) within the ACO. CMS defines primary care physicians as physicians with one of the five following specialty designations: internal medicine, general practice, family practice, pediatric medicine, or geriatric medicine. The second step only considers beneficiaries that have not received a primary care service from a primary care physician, non-physician, or ACO professional providing services at a FQHC/RHC inside or outside the ACO. Under this second step, CMS assigns a beneficiary to an ACO if the beneficiary receives the plurality of his or her primary care services from certain ACO professionals within the ACO. The pre-step as CMS refers to it, specifically refers to “physician” and then proceeds to include other providers in Step 1 and 2 descriptions. Therein lies the problem, at least for the time being. 5. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/Shared-Savings-Losses-Assignment-Spec-V5.pdf Medicare Shared Savings Program SHARED SAVINGS AND LOSSES AND ASSIGNMENT METHODOLOGY Specifications April 2017 Version #5 Applicable Beginning Performance Year 2017