Implementation of Medicare Annual Wellness Visits by Diabetes Specialists in Evolving Healthcare Delivery Models Opportunity for diabetes educators to provide a value-added service as part of the health care team. Proactively identify areas of challenge to address while patient is not sick and to discuss other programs and services with patients.

Disclosures to Participants Notice of Requirements For Successful Completion Please refer to learning goals and objectives Learners must attend the full activity and complete the evaluation in order to claim continuing education credit/hours Conflict of Interest (COI) and Financial Relationship Disclosures: Presenter: Lisa Hodgson, RD,CDN,CDE – No COI/Financial Relationships to disclose Presenter: Judy Carr, MS,RD,CDN,CDE – No COI/Financial Relationships to disclose Presenter: Kimberly Spano, MSN,MSE,BSN, RN – No COI/Financial Relationships to disclose Non-Endorsement of Products: Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activity Off-Label Use: Participants will be notified by speakers to any product used for a purpose other than for which it was approved by the Food and Drug Administration.

Learning Objectives Understand the rationale for, and purpose of, Medicare Annual Wellness Visits (AWVs). Identify the required components of AWVs and the billing codes for this visit type. Recognize the role of the diabetes educator in providing this service in primary care and the value added to practices and patients through this delivery model.

Today’s Presenters Lisa Hodgson, RD, CDN, CDE - Clinical Nutrition Manager, Saratoga Hospital, with over 20 years of experience managing accredited diabetes self-management programs and outpatient nutrition services. Current Member Affiliates Liaison on the AADE Board of Directors. Judy Carr, MS, RD, CDN, CDE - Diabetes Services Quality Coordinator, Saratoga Hospital AADE-accredited Program, with over 20 years of diabetes education and primary care experience. Kim Spano, MSN, MEd, RN, NE-BC - Director of Nursing Practice, Saratoga Hospital Medical Group, with over 30 years of nursing leadership experience. Judy Carr is the Coordinator of Saratoga Hospital’s AADE Diabetes Education Accredited Program, “Diabetes: One Step at a Time.” She works in primary care as a key member of the health care teams at her two locations. Kim Spano is responsible for nursing practice across the rapidly-growing ambulatory care system of Saratoga Hospital. I invite Judy to begin the presentation.

Saratoga Hospital Saratoga Springs, NY 27 PCP’s 8,523 Monthly visits 18 APP’s 102,278 Visits - 2018 Founded in 1891 in Saratoga Springs, NY The only acute-care facility in the greater Saratoga region, just north of the state’s capital, Albany. One of fastest growing counties in state. Magnet facility, affiliated with Albany Medical Center and Columbia Memorial Health System in 2017. The Saratoga Hospital Medical Group, the hospital’s multispecialty practice network, includes more than 240 providers in 32 specialties. 10 primary care locations across rapidly-growing county, 27 physician providers, 18 advance practice practitioners, 102,300 visits in 2018, 8,523 average monthly visits RD’s see patients in 4 primary care centers, 3 specialty offices and an independent office location.

How does the AWV (Annual Wellness Visit) fit into the AADE Vision? Shaping the future of our specialty: position ourselves in a dynamically changing environment elevating our roles – IDENTIFY NEW OPPORTUNITIES TO PRACTICE IN TEAM-BASED, VALUE-BASED SYSTEMS Have heard about Project Vision throughout this conference. As we look at the six pillars guiding the Vision, I would suggest that providing Annual Wellness Visits fits into all of them. Drive integration – coordination of clinical services and self-management training. Achieve Quadruple Aim – reduces costs of care, improves quality by proactively addressing potential issues, improves patient and provider experience. Adds value to role on healthcare team, billable service. Leverage Technology – use of EMR to coordinate services, screenings and preventive care to streamline care and resources. Focus on Behavioral Health – annual visit to screen for behavioral health issues like depression, anxiety and address proactively. Include Related Conditions – screen for unidentified medical conditions, arrange for clinical treatment and self-management training (for any chronic disease) proactively. Promote Person-Centered Care – beneficiaries have the opportunity to meet with their healthcare team once a year to review and discuss areas of concern that may not be addressed at traditional, problem oriented provider visits. May be referred for DSMES and MNT from AWV, pipe line for these and other services.

Why consider implementing AWV? Aligns with 6 pillars of Project Vision Healthcare moves from volume to value Pay for performance (MCR DPP) Referral stream to DSMES, MNT Supports expanded role of educators in primary care practice settings A reimbursable service under MCR – are leaving money on the table!!! Need to maximize revenue stream back to practices and systems. No longer paid by number of patients seen each day, more paid to meet quality measures

Who can implement these visits? RDs, RNs, Pharmacists, other licensed professionals under direct physician supervision (in office suite) Billed under primary care provider, provider receives RVU’s for visits Value-added service provided by other care team members vs. direct billing Outside companies employee RN’s to perform AWV’s for healthcare networks – we can do!

What is the Annual Wellness Visit? Not ‘hands on’ physical exam Focuses on issues important to older adults Considers issues often overlooked Detects emerging health and safety risks Evaluates medication lists Addresses potential food & drug interactions Why provide AWVs to your patients? AWVs are beneficial for patients and providers, even without a physical exam. Patients receive a comprehensive health assessment and personalized prevention plan. Providers are able to better serve patients and keep them healthy. During the AWV, the provider is able to assess the patient and ensure the patient is receiving the right medication, screen for potential problems such as depression, and provide the patient with a prevention plan. In addition, the components of the AWV meet quality metrics that fulfill Quality Payment Program requirements. For organizations participating in the Medicare Shared Savings Program or other alternative payment models, AWVs can be a tool for patient attribution. Lastly, the AWV is a new revenue stream for providers.

IPPE vs. AWV Initial Preventative Physical Examination “Welcome to Medicare” Must be done by MD, DO, NP or PA Once per lifetime - within first 12 months of enrollment in Medicare Part B ONLY Annual Wellness Visit; Subsequent AWV Once per 12-month period thereafter Average time to complete AWV: 20 MINUTES! (Efficient pre-work + team work are essential) Patients are only eligible within the first 12 months of Medicare Part B enrollment for IPPE/ Welcome Preventative Visit While the AWV is available after a Medicare beneficiary has been enrolled in Part B for longer than 12 months, the Initial Preventive Physical Examination (IPPE) is a one-time visit covered within first 12 months of Medicare Part B enrollment. The IPPE must be provided by a physician (MD or DO) or qualified non-physician practitioner (nurse practitioner, physician assistant, or certified clinical nurse specialist). There are four HCPCS codes associated with the IPPE: G0402: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment G0403: Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report G0404: Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination G0405: Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Components of AWV 1. Administer a health risk assessment (HRA) Self-assessment of health; active role for patient Psychosocial risks Behavioral risks ADLs- dressing, walking, bathing, shopping, housekeeping, finances, medication management The AWV encourages patients to take an active role in managing their health, and improve their well-being and quality of life. This is accomplished by evaluation patients’ current health and behaviors, followed by advice and on ways to become healthier. Medicare required a patient to complete a comprehensive HRA to evaluate their current health status, evaluate risk of disease or disability, and assess the safety risks in their home.

Components of AWV 2. Measure vital signs, height, weight, BMI 3. Measure cognitive function (Mini Cog) http://mini-cog.com/wp-content/uploads/2018/03/Standardized-English-Mini-Cog-1-19-16-EN_v1-low-1.pdf 4. List ALL current providers and medical equipment suppliers (care team) 5. Document patient’s medical and family health history

Components of AWV 6. Evaluate for potential risk factors for: Depression (PHQ-9) Social Determinants of Health (SDoH) 7. Review functional ability and level of safety Fall risk; “Timed Up & Go” (TUG) https://www.cdc.gov/steadi/pdf/TUG_Test-print.pdf Hearing impairment Home safety

How To Schedule AWVs Designate specific time slots; days of week One medical professional completes all Hire staff specifically to complete most Telephonic pre-work; followed by shorter visit Flip visits; co-visits Requires trial and error; tailor to practice needs How should I schedule staff to provide AWVs? Each practice must determine the most efficient way to schedule IPPEs/AWVs. Due to the length of the IPPE/AWV, some practices designate specific time slots during the week or specific days for these types of visits. Some practices have chosen to have one eligible medical professional complete all visits, such as a care coordinator, rather than the patients’ primary care providers. Practices that have hired care coordinators may utilize these licensed professionals to complete most or all of the AWV. Determining the most efficient schedule for staff may require some trial and error before the best approach is found. How do I document AWVs in my electronic health record (EHR)? Many organizations have developed templates into their EHRs to capture all of the elements of the IPPE and AWV. These templates include inputs for each component of this visit, including the health risk assessment, list of current providers, medical and family history, depression screening, fall risk assessment, and personalized prevention plan. The health risk assessment includes a patient questionnaire that may be provided to the patient electronically or on paper and later transferred to the EHR.

What billing codes may be used? IPPE – G0402 $172.00 EKG with IPPE – G0403 $21.00 Initial AWV – G0438 $157.00 Subsequent AWV – G0439 $105.00 G0402 Welcome to Medicare Visit (First year only) New to Medicare 1x $172.33 G0438 Initial well visit no longer in 1st year of Medicare 1 per lifetime $157.26 G0439 Annual wellness who have utilized previous services Every 365 $105.26 G0403 Welcome to Medicare EKG 1 per lifetime $21.23 $157 and $105 per MCR benny per year – ADDS UP!!! CMS site can be checked to confirm whether had visit type or not

Can E/M services be provided too? Yes- the appropriate E/M may be billed in addition to the AWV. Report the CPT code with modifier -25 The E/M service is subject to co-payment The AWV can only be billed once in a 12-month period Add E/M code if patient has medical issue needing to be addressed on same day. Co-pays and co-insurance apply to the E/M visit!!! (NOT to the AWV visit!)

Our Pilot Project Identified an opportunity RD, CDE/RN collaborative model to make system impact with limited resources. Selected locations in which providers were already performing AWVs. Calculated potential # AWVs & revenue.

$ Our Potential Revenue Generated $ 9,000 eligible Medicare Part B beneficiaries Only 100 AWVs completed in 2017 Lost revenue potential: $900,000 AND: Payers provide $ incentives to organizations and member participants to complete AWVs above reimbursement 10 primary care practices, 9,000 eligible MCR bennies across system If do 20% of eligible bennies: 1800 AWV’s at $100 per = $180,000 (JUST MCR REIMBURSEMENT!!) Insurers pay for each member to get AWV’s – “downstream revenue” to both practice and member!!! (Example: BC $150 to facility per AWV done!)

Organizational Engagement Essential! Medical Staff and Leadership Members of Care Team Patient Registration, Nursing Staff, Providers Coding and Billing Team Health Information Systems Team Who in my organization should I engage when designing and implementing AWVs? Implementing IPPEs and AWVs requires broad support, beginning with the medical staff and leadership. If completing IPPEs/AWVs is a priority for the practice, it will be successful. Members of the care team, from patient registration to nursing staff to the provider, should understand their role in the process and the workflow for completing the visit efficiently. Working with coding and billing staff early on is important for developing complete documentation and systems to bill for the service. Health information technology staff can build and refine IPPE/AWV templates and assist with queries to identify eligible patients.

Patient Engagement Essential! Education prior to visit is important Patients should be aware: “prevention focus” Designed as no co-pay appointment Outreach - community presentations, during office visits, mailed letter, patient portal, phone calls, Happy Birthday postcard reminder How can I educate patients about AWVs and what to expect? Educating patients prior to the visit is important for achieving patient satisfaction. Patients should be aware that the AWV is focused on prevention and is not an annual physical exam. While the AWV is covered without cost sharing by Medicare, the patient should understand that if they discuss a medical problem during the AWV they will be billed for the Evaluation and Management (E/M) visit and any applicable cost sharing will apply. Some practices have reported that patients sometimes present with a condition or situation at the time of their AWV. Those practices have mitigated this issue by addressing the patient’s immediate issue at that time to provide the visit with no cost sharing. Practices can use many modes to reach patients about the benefits of the AWV. Outreach can be provided in person (e.g., community presentations, during office visit), by mailed letter, by secure electronic messaging in a patient portal, through phone calls, or various other methods. For example, a practice may send a “happy birthday” postcard to patients reminding them to schedule their AWV.

CHALLENGES OF THE AWV PROVIDER PATIENTS PAYER-CMS HEALTH CARE ORGANIZATION Time Management Confusion re: appointment type Coding incorrectly-patient should not be billed Lack of support “Not a Physical” Rural areas experience lower AWV rates Overloaded staff Small practices Lack of EHR Source: Blog Epion Health, 10/02/2018

BENEFITS OF THE AWV PROVIDER PATIENTS PAYER-CMS HEALTH CARE ORGANIZATION Improved quality of care Improved quality of care: improved A1C, decreased fall risk Improved service delivery Patient and revenue growth Provider satisfaction Full range of services available to manage health Improved utilization of strategically placed service Reimbursement opportunity Preventative service-covered at NO cost to patient Proactive identification of patient issues and use of prevention strategies Fosters adoption of team-based care approach Source: Academy of Family Physicians/Quality Insights, March 2018; Medicare AWV Association with Healthcare Quality and Cost, 2019-vol25-n3

Pearls of Wisdom TALK THE NUMBERS – potential revenue. Provider champion is ESSENTIAL. Collaborative effort and support from front line to leadership levels. Start where you have support. Don’t give up and be persistent! It’s the right thing to do! 9,000 annual opportunities, 100 AWV done in 2017 w/multiple billing issues d/t lack of standardized process. Seek out opportunities to provide reimbursable services outside traditional roles, expand opportunities and role. Not direct billable service but bring $$$ to practice/system bottom line!! VALUE PROPOSITION

References Medicare Learning Network: Guide to Medicare Preventive Services, ABC’s of Providing the Initial Preventive Physical Examination https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads

References The ABCs of the Annual Wellness Visit (AWV), CMS Medicare Learning Network, April 2017 The ABCs of the Initial Preventive Physical Examination (IPPE), CMS Medicare Learning Network, April 2017 FAQ on the Medicare Annual Wellness Visit (AWV), American Academy of Family Physicians How to Bill Medicare's Annual Wellness Visit (AWV), American College of Physicians Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV), Noridian Healthcare Solutions, February 2018

Thank you for coming! Lisa Hodgson, RD, CDN, CDE: lhodgson@saratogahospital.org Judy Carr, MS, RD, CDN, CDE: jcarr@saratogahospital.org Kim Spano, MSN, MEd, RN, NE-BC: kspano@saratogahospital.org