1. Improve Outcomes & Revenue
ANNUAL WELLNESS VISITS &
CHRONIC CARE MANAGMENT

2. Agenda Review of CMS Programs: AWV & CCM
Review of CPT/HCPCS Codes and Reimbursements
Current Adoption Rates
Initial Patient Outcome Improvement

3. Annual Wellness Visit
This is a preventive service for Medicare patients to perform a holistic patient assessment, document a preventive services schedule, and outline the annual treatment plan for the patient.
Eligibility:
Medicare Patient
Not in their first 12 months
No IPPE or AWV in last 12 months

4. Codes Initial AWV G0438 Subsequent AWV G0439
Initial AWVs are performed once per lifetime
Use HETS/IVR to obtain AWV eligibility
Subsequent AWV G0439
Subsequent is defined as any AWV performed after the initial
Subsequent AWVs can be performed once per year
Preventive Services can also be performed
Ex: Tobacco Screening
Ex: Advance Care Planning
Coinsurance is waived when billed with an AWV
Ex: Depression Screening
For the initial AWV this service is included in the reimbursement

5. In Clinic Service Elements The ABCs of Annual Wellness Visits
Acquire Beneficiary Information
Review the beneficiary's medical, family, and social history*
Review the beneficiary's potential risk factors for depression, including current or past experiences with depression or other mood disorders*
Review the beneficiary's functional ability and level of safety*
Begin Assessment
Assess the patient: HT, WT, BMI, BP & any other routine measures as deemed appropriate
Detect any cognitive impairment the beneficiary may have
Counsel Beneficiary
Establish a written screening schedule for the patient to use as a 5-10 year checklist*
Establish a list of risk factors and conditions for which primary, secondary, tertiary interventions are recommended or underway for the beneficiary*
Furnish personalized health advice to the beneficiary and a referral, as appropriate, to health education or preventive counseling services or programs*
The services to perform in-clinic are well supported by the previous slide. Each item listed here is required by CMS. Each item listed with an asterisk is one that will be prepared in advance by H3C.

6. Reimbursements & Requirements
Requirements include:
Health Risk Assessment
Current List of Providers
Establish Patient Histories
Review & Document Risk Factors
Review ADLs & Safety
Assess Vitals
Assess Cognition
Draft Screening Schedule
Provide Advice & Education
Provide Care Coordination
Rate by Location
Initial AWV
Subsequent AWV
National Rates
$175.32
$119.16
Missouri – KC Metro
$172.70
$117.14
Missouri – St. Louis Metro
$172.26
$116.83
Missouri – The Rest of MO
$164.03
$110.70
Missouri – RHC AIR
$83.45

7. Chronic Care Management
This is a care coordination program created by Medicare to improve the outcomes of patients with multiple chronic conditions.
Eligibility:
Patient has been seen in last 12 months
Patient has 2+ chronic conditions
Patient has Medicare
Patient has consented to participate

8. History of CCM for FQHCs and RHCs
2016
2017
2018
CCM Codes Released
Direct Supervision Required
Complex CCM is not reimbursed
CCM Codes Remain
General Supervision Allowed
Complex CCM is not reimbursed
CCM Codes Replaced by GCM
General Supervision Allowed
Complex CCM is a factor of reimbursement
2016 payment (CPT Code 99490) – $40.82
2017 payment (CPT Code 99490) – $42.71
2018 payment (Code G0511) – $62.28

9. Care Management Codes Chronic Care Management 99490
Complex Chronic Care Management 99487
Requires medical decision-making
Complex Chronic Care Management (Add-On) 99489
Cannot be added onto 99490
Care Planning G0506
Is only intended to be billed once at initiation of CCM
RHC General Care Management G0511

10. Quick Facts HCPCS Code G0511
Reimbursement is calculated based upon the average of the national rates for:
Chronic Care Management (99490)
Complex Chronic Care Management (99487)
Behavioral Health Integration (CPT 99484)
Billing for the 99490, 99487, or as an FQHC or RHC after 1/1/18 results in denials

11. Chronic Care Management (CCM)
CCM Requirements
20 Minutes
2+ Chronic Conditions
24/7 Access to Care
CEHRT Platform
Chronic Care Management (CCM)
The CCM Care Plan must be signed off by a provider.
The rest of the CCM work can be performed by clinical staff under the general supervision of the provider. Appropriate escalation policies should be put into place.
Items to include:
Medication Reconciliation
Review of Histories
Collaboration with Specialists
Review of Treatment Goals
Baseline Vitals Assessment

12. CCM & GCM Reimbursements
Rate by Location
CCM
Complex CCM
Complex CCM Add On
Care Planning
General Care Management G0511
National Rates
$42.84
$94.68
$47.16
$64.44
n/a
Missouri – KC Metro
$42.23
$92.75
$42.60
$63.45
Missouri – St. Louis Metro
$42.12
$92.48
$46.07
$63.28
Missouri – The Rest of MO
$40.17
$86.92
$43.30
$60.18
Missouri – RHC 
$62.28
Coinsurance:
G0511: 
DOS is a calendar month
Applies
Can be a stand alone claim
Revenue code 052x
CANNOT be waived
CANNOT be billed with TCM services
20% of charges
Is NOT factored into the RHC AIR

13. The Cost of Chronic Disease
Between 2016 – 2030 the estimated cost of Chronic Disease is $42 Trillion. Only 5% of people account for 50% of that overall healthcare spend.
Every 30 seconds, a patient
has a limb amputated due to untreated or exacerbated diabetes.
Patients with chronic conditions account for 81% of overall U.S. hospitalizations
The partnership to fight chronic disease estimates that 16 million lives can be saved over the next 12 years with improved chronic disease management.
Chronic disease accounts for 7 of every 10 deaths in the U.S.

14. Across the Nation: CCM Participants
Total Medicare Beneficiaries: 55,550,400
Average 64% Eligible: 35,552,256
Actual CCM Services: ,000
1.9% of eligible patients
Here you can see that of 55M beneficiaries over 35M on average were eligible for CCM. Services were performed for just over half a million patients. To put that in perspective that’s the equivalent of treating less than 2 of every 100 patients. This is 2015 data so the number of beneficiaries and the number that are CCM eligible have actually increased to 58 Million beneficiaries and 70% eligible for CCM. However, as retrospective data goes, we have the most on 2015.

15. The Nation vs. Missouri 67% The Average for Missouri The Nation
AWVs Performed
17% of eligible
18% of eligible
Diabetic Screenings
3% of eligible
5% of eligible
67% of Missouri Medicare patients have two or more chronic conditions.
On average they cost $4,421 per patient per year due to lack of management.
For every 100 patients discharged after an AMI, 15 are readmitted.
For every 100 patients discharged after heart failure, 20 are readmitted.
In rural hospitals these numbers are usually higher, one rural hospital in Missouri averages 74 readmissions for every 100 discharged heart failure patients.

16. Chronic Care Management Study
YOUR NEEDS AS AN ACO

17. Patient Outcome Data

18. CMS Study Findings Patient satisfaction higher
Improved Adherence to recommended therapies
Improved clinician efficiency
Decreased hospitalizations and ED visits
Enhanced patient access through CM
More frequent condition management b/n visits
Improved Med Reconciliation

19. AWV Outcome Data
Large enterprise data analytics organization
Represent over 200 ACOs and Hospitals
“Overall we have seen a 44% reduction in cost for patients who’ve had an AWV versus patient’s who have not across our shared risk and/or shared savings participants”

20. AWV Reference Tools The ABCs of The AWV CDC Advisory Committee (ACIP)
A Framework for HRAs
Medicare Preventive Services Tool
US Preventive Services Taskforce
CMS MAC Contractor Map

21. Thank You Taya Moheiser, CMPE Advisory Services Director Taya
Thank You Taya Moheiser, CMPE Advisory Services Director Elizabeth Chandler Director, Strategic Accounts

22. Resources The ABCs of the Annual Wellness Visit (AWV)
Rural Health Clinic (RHC) Preventive Services Chart
Update to Rural Health Clinic (RHC) All Inclusive Rate (AIR) Payment Limit for Calendar Year (CY) 2018
The Medicare Physician Fee Schedule
Mathematica Report: Evaluation of the Diffusion and Impact of the Chronic Care Management (CCM) Service: Final Report 11/2/2017
Care Management Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)