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

2. 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.

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

4. 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.

5. 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. )

6. 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.

9. Step 1: Acquire History

10. Step 2: The “Examination”

11. Step 3: Education and Counseling

15. 15 15

16. 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.

17. 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.”

18. 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.

19. 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.

20. 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.

21. 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

22. 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

23. 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 –99215 may be reported depending on the clinical appropriateness of the circumstances.
•Preventive services identified in CPT code range through 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.

24. 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.

25. 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.

26. 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

27. 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

36. Step 1: Acquire History

37. Step 1: Acquire History

38. Step 2: The examination

39. Step 3: Counsel Beneficiary

40. 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.

41. 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.

42. 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.

43. Step 1: Acquire History 43 43

44. Step 2: The examination

45. Step 3: Counsel Beneficiary

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

47. 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

48. 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

49. 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)
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

50. 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

51. 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

52. 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

53. 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.

54. 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

55. 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)

56. Annual Wellness Visit-Points to Remember
G0402: Welcome to Medicare visit, IPPE, first 12 months of eligibility for part B
G Annual wellness visit (AWV), Once a year or 12 months after Welcome to Medicare visit
G 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

57. 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.

58. 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

59. 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

60. 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

73. Resources AAFP:American Association of Family Practice
s/fpm/preprint/healthriskassessment.html
CDC: Center For Disease Control
79.pdf

74. Resources
The guide to Medicare Preventive Services s/mps_guide_web pdf
The ABCS of providing the annual wellness visit s/AWV_chart_ICN pdf

75. Medicare covered preventive services 2017
QUESTIONS?