1. Multidisciplinary Multi- Department Medicare Annual Visit Performance Improvement Project Eric M. Wiser, MD; Colleen Casey, PhD, ANP-BC, CNS; Ann Tseng, MD; Emily Michelle Barclay; Karen Aiello, CMPE

2. Disclosures We have nothing to disclose.

3. Overview Define current visit types Discuss logistical issues Show payment rates before intervention Describe our current process Look at post intervention payment rates

5. Who we are Family Medicine Department –Residency –4 clinics 2 on Epic 2 on OCHIN Internal Medicine –Geriatrics clinic –Resident clinic –Attending clinic Health Sports Medicine Center for Women’s Health

6. Group Members 29 representatives from: –Center for Women’s Health, Family Medicine, Internal Medicine –Rehabilitation services –HOS –Professional Services Coding –Integrity Office –UMG –Clinical Informatics

7. Goals of the MWV committee Reach compliance Increase billing accuracy Meet other metrics –SBIRT –Falls screening Not burdensome System wide

8. Problems with MWV Health Risk Assessment (HRA) Multiple types of visits –IPPE (G0402) –AWV initial (G0438) –AWV subsequent (G0439) –Preventative Visits (99397 or 99387) The visits have different eligibility The visits have different requirements MedAdvantage plans –Some prefer MWV, some like preventative visits Depends on the contract

9. Other Considerations Depression Screening –PHQ 2 –PHQ 9 –SBIRT Falls Screening (PQRS) –STEADI Health Risk Assessment

10. STEADI Falls prevention program developed by the CDC State wide prevention programs Grant with Geriatrics Satisfies PQRS

11. 6 month review by IM

12. Scheduling Errors

13. Provider Errors

14. MA Errors

15. Patient Errors

16. Summary Scheduling –Wrong visit IPPE vs AWV vs Preventative –Wrong time Provider made the majority of errors –Wrong visit Incomplete Data

17. Lost revenue MWV performed not billed Preventative codes used (99397 or 99387) –Not a benefit on Medicare and many MedAdvantage plans Can convert a MWV to a 99387 –$117 for a preventative visit vs $140 MWV 99213 No annual visit performed at all

18. Billing work arounds If a visit wasn’t compliant it was written off and then not charged to the patient. –ZWO In 2013 University Wide –1206 visits were scheduled All MWV and preventative wellness visits (age 65 or over) –752 were paid 439 MWV 313 Preventative –286 ZWO

19. Breakdown by site Gabriel ParkCHHRichmondScappoose MWVs in 2013: Total number of completed visits: 160115n/a Total billed to insurance:84 (53%)35 (30%)1711 Total paid:76 (90%)33 (94%)14 (82%)9 (82%) Preventative Visits in 2013 # of visits scheduled 90248n/a Total billed to insurance: *MWVs without sufficient documentation are changed to Preventive codes. Some MCR payors will pay for Preventive codes. 138*258*8841 Total paid: 43 (31%)33 (13%)63 (72%)37 (90%)

20. Requirements

21. Summary of Issues Scheduling –Within 12 months of Medicare enrollment –Which visit type Preventative IPPE, AWV –365 days since last visit Provider –Documentation –Choosing the correct code Billing –IPPE/Welcome to Medicare (G0402); AWV Initial (G0438), Subsequent AWV (G0439)

22. Pitfalls Pt expectations –MWV is not problem based Co-billing –Physical Exam “I just want my yearly physical”

23. Questions/Comments

24. Working Timeline (2014)

26. Have you been seen in clinic in the last 12 months? Yes Has it been 365 days since last preventive visit? Yes Do you have Medicare or MedAvantage plan regardless of age? Yes Follow script to the side Do you still want to schedule a Medicare Wellness visit? Yes Schedule Medicare Wellness visit and mail out packet with letter No Schedule office visit No Schedule Non-Medicare preventive visit (Annual or Physical) No Schedule office visit and let pt know they can only have one preventive visit per 365 days Schedule preventive/wellness visit at least 365 days from the time of the last preventive visit No Schedule office visit Schedule New/Est care office visit

27. Phone Script PAS: Great. I will help you schedule this visit. I am required to share the following information with you: Medicare covers a wellness visit once per year that focuses on preventative care and screenings. If you and your provider decide there are more pressing medical issues which are not preventative, you may need to reschedule your Medicare Wellness visit. You will receive a letter from us with more information about this type of appointment. See Medicare Wellness cover letter as needed to answer patient questions about what is covered or not covered if they ask specific questions

28. HRA Goal was to incorporate current screening tools into the HRA process. –Eliminate depression screening and use SBIRT Utilize STEADI for falls screening Have elements that are in the HRA and the visit note get imported into the provider note –Helps with provider documentation

30. HRA Required topics Demographic data, including but not limited to: –a ge – gender – Race – ethnicity Self assessment of: – health status frailty – physical functioning Psychosocial risks, including but not limited to: – depression/life satisfaction –stress –anger –loneliness/social isolation –pain –fatigue Behavioral risks, including but not limited to: –tobacco use –physical activity –nutrition and oral health –alcohol consumption –sexual health –motor vehicle safety (seat belt use) –home safety

31. HRA Required Topics Cont. Activities of daily living, including but not limited to: –dressing –feeding –toileting –grooming –physical ambulation (including balance/risk of falls) –bathing Instrumental activities of daily living (IADLs), including but not limited to: –shopping –food preparation –using the telephone –housekeeping –laundry –mode of transportation –responsibility for own medications –ability to handle finances

32. MA Data Entry Doc Flowsheets –SBIRT –HRA –STEADI Low risk STEADI High risk –Ortho statics –Vision –TUG PCP Care Team –Consultants –DME suppliers

33. Data Entry Workflow MA completes data entry at the visit –40 minute appointment Panel Manager collects data over the phone prior to the visit –15 minute appointment for a low risk patient –30 minutes for a high risk patient MyChart interface

34. HRA docflowsheet

35. Care team-MA enters Enter Care Team through Visit Navigator Enter DME through HRA

36. STEADI DocFlowsheet- MA enters

37. Provider Role Review the Health Risk Assessment, including DME Review the SBIRT data Review the STEADI Falls Risk Assessment –If score ≥ 4, MA will have performed a Timed Up and Go, Vision Screen and Orthostatics –Recommend a f/u visit to complete STEADI provider evaluation Use the MWV Smartset to access the Note Template and enter orders Provide patient with Medicare AVS (via Smartset)

38. Requirements

39. MWV smartset

42. MWV note template PE not required Cognitive screen based on age/history

43. MWV note template

44. MWV-STEADI Workflow is to schedule separate OV for high risk (≥4) –STEADI Smartset has orders and note template For low risk patient (≤3), sign both Assess/Plan in MWV Smartset For high risk patient, sign Assessment only ABIM/ABFM credit is possible with paperwork filed

45. MWV AVS-required Use F2 FUNCTION TO CUSTOMIZE TO EACH PATIENT

46. MWV-additional info THESE EXPAND FOR MORE INFO

47. MMV-With E&M Well reimbursed by most insurance companies. Problem should not be something straightforward or simple (i.e. rash, cold, etc.). Refilling medications for chronic conditions does not warrant a separate E&M. The documentation should have a separate note, within the same encounter, for the E&M portion of the visit. –All history, exam and MDM obtained/performed for the problem portion of the visit should be documented there. –It should not be mixed in with the MWV template information. When billing based upon time for the E&M portion, the time should state it was exclusive of the time spent performing the MWV.

48. Coding and Billing After completion of documentation the provider routes the note to the coder Coder will then determine which code to bill –IPPE –AWV –Preventative If the claim is rejected then the code will be readjusted

50. Started slow We started with one provider/MA –Did a MWV day –Timed each portion –Worked out the kinks of the template and work flow Moved to one clinic

51. Education Front office education –New workflows –New visit types MA –Doc flowsheets –STEADI Providers –STEADI –Smart set

52. Current Success 70 Visits completed –2 visits did not have a vision screen for IPPE –4 the provider did not use the template –5 visits were denied for benefit issues 2 visits were completed prior to 365 days from the previous visit out at our office 3 visits were completed at another office 59/70 were completed correctly (84% success rate)

53. Summary Creation of a single MWV was successful –Simplified scheduling, eligibility, billing issues Updated EMR tools Workflows and education –PAS –MA –Provider Participation of the entire office is required to perform these visits successfully.

54. References QUICK REFERENCE INFORMATION: The ABCs of Providing the Initial Preventive Physical Examination (IPPE) QUICK REFERENCE INFORMATION: The ABCs of Providing the Annual Wellness Visit (AWV) STEADI –http://www.cdc.gov/steadihttp://www.cdc.gov/steadi Hughes, C. Medicare Annual Wellness Visits Made Easier. Fam Pract Manag. 2011 Jul-Aug; 18(4) 10-14 Hughes, C. Medicare Annual Wellness Visits: Don’t Forget the Hearth Risk Assessment. Fam Pract Manag. 2012 Mar-Apr; 19(2): 11-12 Cuenca, A. Making Medicare Wellness Visits Work in Practice. Fam Pract Manag. 2012 Sep-Oct; 19(5): 11-16

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