Preventative Medicine & Medicare Karrie May, CPC, CPMA March, 2017

Karrie May, CPC Been in the medical field in some capacity for over 25 years. Currently work for a large medical facility as a provider educator/auditor.

TOPICS Welcome to Medicare visit Annual Wellness Visit, Initial Annual Wellness Visit, Subsequent Preventive Care covered by Medicare

WELCOME TO MEDICARE VISITS Medicare covers the “Welcome to Medicare” visit within the first 12 months of patient’s coverage with Part B. Initial Preventive Physical Exam (IPPE) or the Welcome to Medicare visit is to review the patient’s health. To provide education and counseling about preventive services, and referrals for other care if needed. There is no co-pay or deductible for this visit.

WELCOME TO MEDICARE VISITS cont IPPE includes the following components: Height, weight, blood pressure body mass index and visual acuity. Review of Medical & Social History Review of potential risk factors for depression, functional ability and level of safety with the goal of health promotion and disease detection EKG (no longer a mandatory part of the IPPE, but it may be performed as an optional one-time service as a result of a referral arising out of the IPPE. )

WELCOME TO MEDICARE VISITS cont IPPE includes the following components: Education, counseling, and referral with respect to screening and preventive services currently covered by Medicare Part B Covered Immunizations (review & future plan) End-of-life planning upon an individual’s consent.

Step 1: Acquire History

Step 2: The “Examination”

Step 3: Education and Counseling

15 15

WELCOME TO MEDICARE VISITS cont When patients call to schedule this visit they will probably ask for their free physical. This is not a “head to toe” physical. Only requirement is height, weight, and BMI. A complete physical doesn’t require as much paperwork or as much time as the IPPE. The RVU’s for the IPPE are higher than for a complete physical.

WELCOME TO MEDICARE VISITS cont Patients will ask for their free physical, there is no such thing as a free physical. Medicare doesn’t cover physicals Scheduling staff needs to be trained to ask more questions. For example “Are you calling to schedule your Annual Wellness visit or Initial Wellness Visit? If so this is not a physical. If you want to have a physical it is not covered by Medicare and you will be responsible for the payment of the charges.”

WELCOME TO MEDICARE VISITS cont Are you feeling sick or do you have serious problems you wish to discuss with the doctor? If so you can reschedule your Wellness visit and come in to see the doctor today and pay your co-ins or deductible. The AWV or IPPE is covered with no deductible or co- insurance but if you and the physician discuss your medical problems at length then you will be billed an additional visit and will be responsible for the coinsurance or deductible for this visit.

WELCOME TO MEDICARE VISITS cont The clinical staff needs to also be aware that the patient is there for their AWV or IPPE. They want to make sure the patient stays dressed and is not asked to disrobe as if to have a physical. They may help the patients fill out the paperwork for the visits as long as the physician reviews all of the paperwork the staff is able to help the patients.

WELCOME TO MEDICARE VISITS cont The patient may be eligible for an abdominal aortic aneurysm (AAA) screening. It must be ordered at the time of the Welcome to Medicare Visit (IPPE). Must be performed within six to twelve months from the visit. Once in a lifetime benefit. If patient is an established patient to the practice, they can still receive the IPPE. The ekg and AAA will still have deductibles if they apply.

WELCOME TO MEDICARE VISITS cont Code G0402: Initial Preventive Physical Examination (IPPE); face to face visit, services limited to new beneficiaries during the first 12 months of part B eligibility. ICD-10 Z00.00 IPPE EKG codes: G0403: EKG tracing and report   G0404: EKG tracing only G0405: EKG interpret & report only  ICD-10 Z13.6 is the same for all three of these codes 21 21

WHO CAN PERFORM IPPE The IPPE must be furnished by a health professional, meaning a physician, a qualified physician assistant, nurse practitioner or clinical nurse specialist. Can also be performed by a medical professional, including health educators, registered dietitians, nutrition professionals, or a team of such medical professionals who are working under the direct supervision of a physician. All must be licensed and this must be within the scope of their practice 22 22

Providing E/M services in addition to IPPE •Appended to claims denoting a separate Evaluation and Management (E/M) service furnished with an IPPE. •Cost sharing (coinsurance, copayment and deductible) applies to the additional (E/M) service. •CPT codes 99201 –99215 may be reported depending on the clinical appropriateness of the circumstances. •Preventive services identified in CPT code range 99381 through 99397 are not covered by Medicare. NOTE: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable, E/M service.

Annual Wellness Visits As of 2011, Health care reform extended the preventive focus of Medicare to provide coverage for Annual Wellness Visits (AWV) This is not a physical it is an evaluation of the patients health and wellness. Many patients will call and ask for their free physical, it is very important for the patient to know that this is not a head to toe physical.

Annual Wellness Visit for Medicare Who is Eligible for an Annual Wellness Visit? A beneficiary that has not received either an initial preventive physical examination, IPPE or an AWV within the past 12 months. It is possible to find out if the patient has seen another physician for these services, contact the carrier in your jurisdiction to find out how to verify this.

What is Included in an Initial AWV? Establish or update the individual’s medical and family history Depression screening List of individual’s current medical providers, suppliers and all prescribed medications Record Vitals to include height, weight, body mass index, blood pressure and other routine measurements

What is Included in an Initial AWV? Functional ability-includes hearing test Detect any cognitive impairment Create a schedule of Medicare’s screening and preventive services for next 5-10 yrs Any required referrals to treat potential health risks

Step 1: Acquire History

Step 1: Acquire History

Step 2: The examination

Step 3: Counsel Beneficiary

What is Included in a Subsequent AWV? An update of the individual’s medical/family history. An update of the list of current providers. Measurement of an individual’s height, weight, BMI, BP, and other routine measurements.

What is Included in a Subsequent AWV? An update of the individual’s medical/family history. An update of the list of current providers Measurement of an individual’s height, weight, BMI, BP, and other routine measurements.

What is Included in a Subsequent AWV? Detection of any cognitive impairment. An update to the written screening schedule. An update to the list of risk factors. Furnishing of personalized health advice.

Step 1: Acquire History 43 43

Step 2: The examination

Step 3: Counsel Beneficiary

Annual Wellness Visit G0438 - Annual wellness visit, first visit. G0439 – Subsequent annual wellness visit Preventive Medicine codes 99387 and 99397 better known to offices as Complete Physical Exams or Well Checks for 65 and older, remain a non-covered, service from Medicare.

Preparing Eligible Medicare Beneficiaries for the AWV Providers can help eligible Medicare beneficiaries get ready for their AWV by encouraging them to come prepared with the following information: Medical records, including immunization records; Family health history, in as much detail as possible; A full list of medications and supplements, including calcium and vitamins – how often and how much of each is taken; and A full list of current providers and suppliers involved in providing care. The Annual Wellness Visit is a review of the patient’s health and a plan to keep them healthy. It does not include comprehensive physical exam (head-to-toe) however if: If the patient has one or two additional medical problems the physician may choose to treat at the same time as the wellness visit. These additional problems will be subject to the deductible/co-insurance 47 47

Preparing Eligible Medicare Beneficiaries for the AWV A new requirement as of 2012 is a Health Risk Assessment (HRA) The purpose of the HRA is to determine the health behaviors and risk factors of the patient. Must be completed by the patient before the face to face encounter with the physician. The Annual Wellness Visit is a review of the patient’s health and a plan to keep them healthy. It does not include comprehensive physical exam (head-to-toe) however if: If the patient has one or two additional medical problems the physician may choose to treat at the same time as the wellness visit. These additional problems will be subject to the deductible/co-insurance 48 48

Preparing Eligible Medicare Beneficiaries for the AWV CMS has not designated a specific form but it does have 34 required elements that need to be addressed. The CDC has collaborated with the Centers for Medicare and Medicaid Services (CMS) to develop an evidence-informed framework document for this type of assessment, A Framework for Patient- Centered Health Risk Assessments: Providing Health Promotion and Disease Prevention Services to Medicare Beneficiaries . (PDF, 3 MB) http://www.cdc.gov/policy/opth/hra/ The Annual Wellness Visit is a review of the patient’s health and a plan to keep them healthy. It does not include comprehensive physical exam (head-to-toe) however if: If the patient has one or two additional medical problems the physician may choose to treat at the same time as the wellness visit. These additional problems will be subject to the deductible/co-insurance 49 49

Preparing Eligible Medicare Beneficiaries for the AWV Form must be written at sixth grade literacy level, must be able to complete in 20 minutes. This form can be completed by the patient or the caregiver and it must be completed before the face to face encounter with the physician. HRA can be accessed via internet, phone, or paper based. Must be accessible to all in a language familiar to them. The Annual Wellness Visit is a review of the patient’s health and a plan to keep them healthy. It does not include comprehensive physical exam (head-to-toe) however if: If the patient has one or two additional medical problems the physician may choose to treat at the same time as the wellness visit. These additional problems will be subject to the deductible/co-insurance 50 50

Preparing Eligible Medicare Beneficiaries for the AWV If the HRA is filled out in the physicians office the office staff can help the patients complete the form. Medicare has increased RVUs for this procedure. Medicare does not expect this to be a brief visit. The Annual Wellness Visit is a review of the patient’s health and a plan to keep them healthy. It does not include comprehensive physical exam (head-to-toe) however if: If the patient has one or two additional medical problems the physician may choose to treat at the same time as the wellness visit. These additional problems will be subject to the deductible/co-insurance 51 51

Annual Wellness Visit-Points to Remember No specific required diagnosis code. Use a preventive diagnosis code. The AWV is an excellent opportunity to gain an overall view of your patient’s health status, and to ensure you’ve documented all clinical conditions that are relevant. The Annual Wellness Visit is a review of the patient’s health and a plan to keep them healthy. It does not include comprehensive physical exam (head-to-toe) however if: If the patient has one or two additional medical problems the physician may choose to treat at the same time as the wellness visit. These additional problems will be subject to the deductible/co-insurance

Annual Wellness Visit-Points to Remember Medicare allows payment for a medically necessary Evaluation and Management (E/M) service on the same date as AWV, provided it is clinically appropriate. The patient will owe a co-pay for this service. Some of the components of a medically necessary E/M service may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of service to be billed. The E/M visit should be coded with the addition of modifier 25.

Annual Wellness Visit-Points to Remember If the patient wants to schedule an AWV or IPPE and they have a lot of medical concerns, suggest they schedule a medical visit first and then schedule the AWV or IPPE after that. If patient is insisting on physical (head to toe) suggest the AWV or free visit first, and if they still feel they need the physical they can schedule it. Complete physical is a non covered service, the patient will be responsible for payment in full. If the patient desires an annual physical, complete an ABN to show patient the cost. 54 54

Annual Wellness Visit-Points to Remember Do not add modifier -25 to Medicare G code. Use additional codes to report the following services during an IPPE or AWV: Screening Pelvic Exam (Code G0101) Screening Pap Tests (Code Q0091) Screening Prostate Cancer (code G0102)

Annual Wellness Visit-Points to Remember G0402: Welcome to Medicare visit, IPPE, first 12 months of eligibility for part B G0438 - Annual wellness visit (AWV), Once a year or 12 months after Welcome to Medicare visit G0439 - Annual wellness visit (AWV), subsequent visit, 12 months after the last AWV Make sure patient is aware of the differences between these two visit types (only for Medicare Patients) First goal is to offer the covered services to Medicare patients Make sure patient is healthy enough to have an AWV If patient is very ill, schedule a problem oriented visit (routine office visit) prior to his/her AWV appointment

Covered Preventive Services Alcohol misuse screening and Counseling AWV Bone mass measurements Cardiovascular Disease Screening tests Colorectal Cancer Screening Counseling to prevent tobacco use Depression screening Diabetes screening Diabetes self management training Effective Jan. 1, 2011, Health Care Reform waives the Part B deductible and the 20 percent coinsurance to most preventive services.

Covered Preventive Services Glaucoma screening Hepatitis B Virus Vaccine and Administration Hepatitis C Virus Screening Human Immunodeficiency Virus (HIV) Screening Influenza Virus Vaccine and Administration IPPE Exam Welcome to Medicare Intensive Behavioral Therapy for Cardiovascular Disease Intensive Behavioral Therapy for Obesity 58 58

Covered Preventive Services Lung cancer screening counseling and annual screening for lung cancer with low dose computed tomography Medical Nutrition Therapy Pneumococcal Vaccine and Administration Prostate cancer screening Screening for Cervical cancer with human papillomavirus HPV tests Screening for sexually transmitted infections and high intensity behavioral counseling to prevent STI’s 59 59

Covered Preventive Services Screening Mammography Screening Pap Tests Screening Pelvic Examinations (includes a clinical breast exam) Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) 60 60

Resources AAFP:American Association of Family Practice http://www.aafp.org/online/en/home/publications/journal s/fpm/preprint/healthriskassessment.html CDC: Center For Disease Control http://www.cdc.gov/policy/opth/hra/ Http://www.medicarehealthassess.org/ http://www.howsyourhealth.org/ https://www.cms.gov/MLNMattersArticles/downloads/MM70 79.pdf

Resources The guide to Medicare Preventive Services http://www.cms.gov/MLNProducts/download s/mps_guide_web-061305.pdf The ABCS of providing the annual wellness visit http://www.cms.gov/MLNProducts/download s/AWV_chart_ICN905706.pdf http://www.cms.gov/PreventionGenInfo

Medicare covered preventive services 2017 QUESTIONS? Kmaycpc@yahoo.com