NEW ORLEANS – Annual Medicare wellness exams are being unperformed, resulting in lost opportunities and revenue, according to Dr. Mary M. Newman.
In 2011, more than 32 million Medicare beneficiaries in the traditional program (excluding Medicare Advantage) received one or more of the covered services, which are free for enrollees. They include the "Welcome to Medicare," or Initial Preventive Physical Examination (IPPE); the annual wellness visit; and other preventive services that may occur outside those visits. So far in 2012, 8.9 million enrollees have received a free service, including 562,000 who had an annual wellness visit. That’s up from the 312,809 beneficiaries who received the wellness visit during the first 3 months of 2011, according to the Centers for Medicare and Medicaid Services.
The program got off to a slow start because of an awareness gap, Dr. Newman said. Also, correctly coding and billing for the visits takes practice. An electronic health record aids in delivering the benefits consistently and well.
Dr. Newman, an internist at a group practice in Lutherville, Md., explained that Medicare pays about $166 for the initial wellness visit, with subsequent visits paid at a slightly lower rate. The typical office visit for a Medicare patient is reimbursed at about $70. In addition, the CMS is paying a slight premium for the wellness visits starting this year because the agency is now requiring the completion of a health risk assessment for each beneficiary.
Before the Affordable Care Act, only one preventive/wellness visit was covered for beneficiaries during their lifetime. Now, the IPPE visit initiates a continuum of care, with an update on the care plan and screenings on an annual basis. The IPPE visit, which must be used in the first 12 months after a beneficiary is enrolled, includes a medical/surgical history; review of current medications and supplements; family history; history of alcohol, tobacco, and illicit drug use; and discussion of diet and physical activity. Risk factors for depression should be reviewed and functional ability assessed.
The basic physical exam covers blood pressure, vision, weight, and height. Written or verbal end of life planning should be offered, and recommended screenings and vaccinations should be checked. The findings are used to compile a written care plan, complete with recommendations for screening or other preventive services. Annual wellness visits then follow, but annual visits also can occur without having first had the IPPE, according to the CMS.
The IPPE is billed using the G0402 visit code and the V.70 diagnosis code, said Dr. Newman. The first annual wellness visit is billed using the G0438 code, and each subsequent visit uses the G0439 code. The wellness visit can be conducted by a physician or any medical professional working under a physician’s supervision.
Before each visit, Dr. Newman’s practice staff verifies that patients are eligible for either the IPPE or the annual wellness visit and explains the visit and what’s covered. Patients are also encouraged to fill out a form they can download from the practice’s website that helps them organize their medication list, family history, and names of all current physicians.
During the initial wellness visit, Dr. Newman conducts a two-question depression screen and a four-question functional assessment. She has patients walk the hallway as she observes them for motor skill, balance, and other functional measures. After discussing preventive care and advance directives, assessing risk factors, and taking vital signs, she issues a written care plan.
The plan includes a list of risk factors and conditions; referrals for screening tests and, as appropriate, nutritional counseling, smoking cessation, fall prevention, and weight loss; a screening schedule for 5-10 years; and end of life planning. It is updated at each subsequent wellness visit. This is where an EHR can really help, she noted. Ask the vendor to embed the wellness elements, and that way it can be simply updated.
In addition to the wellness visits, a host of preventive services are covered, but there are rules for how the services are delivered, she said. For instance, beneficiaries can receive a one-time screen for abdominal aortic aneurysms; the referral must be made during the first year someone is on Medicare, and they must have certain specific risk factors.
Bone density tests are covered every 2 years. Beneficiaries are liable for 20% of the service if the physician does not accept assignment. New benefits added in 2012 include screening and counseling for alcohol misuse and for sexually transmitted diseases for high-risk patients. Once-a-year screening for depression is covered; if the patient is depressed, the physician must have a care plan.