Understanding Annual Wellness Visits
In January 2011, Medicare began covering an Annual Wellness Visit (AWV), a new benefit resulting from the Affordable Care Act. The AWV takes place with one’s primary care provider, is covered once every 12 months after the first year of Medicare coverage, and has no deductibles, coinsurance, or copayments.
Among other things, the Annual Wellness Visit includes the provider taking a medical history, a health risk assessment, an evaluation of the patient’s physical condition, and a screening for depression as well as cognitive impairment. It also includes a personalized prevention plan, where the provider develops a strategy with the patient to manage his or her health, including planning the preventive services and screenings a patient may need over the next 5 to 10 years. This prevention plan helps patients take advantage of Medicare’s preventive services. Also resulting from ACA, eliminating the cost-sharing for many preventive services covered by Medicare marks a major milestone in Medicare’s efforts to keep beneficiaries healthy rather than just paying for treatment when they are sick.
The Annual Wellness Visit is different from the Welcome to Medicare visit. The Welcome to Medicare visit is for beneficiaries new to Medicare. Neither the AWV nor the Welcome to Medicare visit is a routine physical exam. Both provide patients with an opportunity to talk with a provider about health concerns.
Assessment and Care Planning for Patients with Cognitive Impairment
CMS has adopted the code G0505 to provide separate payment to recognize the work of a physician or QHP in assessing and creating a care plan for beneficiaries with cognitive impairment, such as from Alzheimer’s disease or dementia, at any stage of impairment. Only physicians and other QHP’s may provide the central elements of this service and report code G0505.
G0505 is a cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, in office or other outpatient setting or home or domiciliary or rest home
The following service elements are required to support reporting of G0505.
Code G0505 may not be reported with other face-to-face services such as evaluation and management services, psychiatric evaluation or treatment, or advance care planning. However, this service may be reported in the same period as chronic care management, transitional care management, or behavioral health integration services when the patient eligibility and code criteria are met for each.
Transition Care Management
Readmission rates are a focal point in healthcare today, and used to judge a healthcare organization’s overall quality of care. However, the hospital doesn’t have control over whether the patient follows discharge plans. We can now guide each patient on the road to recovery post-discharge.
Advanced Care Planning
Advance care planning (ACP) is a voluntary process, in which patients can set on record choices about their care and treatment and, in particular, any advance decision to refuse a treatment in specific circumstances, including those where they may have lost capacity in the future.
When it is billed with the AWV, the deductible and coinsurance for ACP are waived. If the AWV is billed with ACP and denied for exceeding the once per year limit, payment could be made for the ACP service if it is medically necessary. In that case, the deductible and coinsurance are applied to the ACP.
Why participate in the BOCO Medical Preventive Services Program?
TURNKEY & COMPREHENSIVE Solution:
The Benefits of a BOCO Medical AWV Program:
Revenue is generated for the primary care physicians by the wellness visits. This helps motivate the physicians and keep them in a positive and upbeat framework as the ACO begins to get on its feet. Even though the Annual Wellness Visit revenues are “costs” from the ACO perspective, we consider this to be an “investment” in the long-term profitability of your ACO. By investing in your patients with Annual Wellness Visits, you will reduce your spending on the backside and minimize your hospital admissions, reduce long term care costs, and cut other Medicare costs. This will result in increased profitability for your ACO.
Since ACOs operate upon a shared savings model, it is imperative that the overall cost of patient care is driven down. An Annual Wellness Visit brings each patient in front of his or her physician every single year and gives the physician a consolidated list of risk factors for those patients. With these risk factors in hand, the physicians can take proactive care and prevent the onset of catastrophic injury, hospitalization, surgeries, chronic illness, long term care, and nursing home stays. By keeping these costs down, the ACOs overall spend rate will decrease dramatically.
Data is generated in sizable quantities and is of excellent quality. Each AWV visit generates over 250 data points. When this data is linked to the claims and lab results of the ACO, the majority of the 33 Measures required by Medicare can easily be reported back to the ACO. The data our program generates is impressive. This data is made available to you on demand whenever you need it.
Finally, a well-orchestrated wellness program causes inactive patients to become active patients. This increases the attribution of the ACO roster and the ACOs shared savings increases proportionately. This can result in tens of millions of additional revenue dollars back to the ACO.
Frequently Asked Questions (FAQs):
Does Medicare Provide any Documentation on the AWV?
Yes. For details, please visit the CMS website at https://www.cms.gov/outreach-and-education/outreach/npc/downloads/ippe-awv-faqs.pdf.
If a beneficiary has never had an IPPE, does Medicare cover an Ultrasound Screening for AAA ordered based on an AWV referral?
No, Medicare does not cover the ultrasound screening for AAA when ordered based on an AWV referral. Medicare coverage for a one-time ultrasound screening for AAA depends on the beneficiary meeting certain eligibility requirements, including receiving a referral as a result of an IPPE.
Can I bill a separate Evaluation and Management (E/M) service at the same visit as the AWV?
Medicare may pay for a significant, separately identifiable, medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201 – 99215) billed at the same visit as the AWV when billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.
Do deductible or co-insurance/co-payment apply for the AWV?
No, coverage for the AWV is provided as a Medicare Part B benefit. Medicare waives both the coinsurance or copayment and the Medicare Part B deductible for the AWV.
Is the AWV the same as a beneficiary’s yearly physical?
No, the AWV is a preventive wellness visit and is not a “routine physical checkup” that some seniors may receive every year or two from their physician or other qualified non-physician practitioner. Medicare does not cover routine physical examinations.
How do I bill Medicare for the follow-up visit(s)?
Use standard E&M coding with procedures if required. This is the same billing to Medicare you’ve been using for years.
What if my patients complain about being treated by a nurse, mid-level, or CMA instead of a physician?
Tell them honestly that the wellness visit is a data gathering session that leads to a visit with the doctor if warranted. The data gathered by the nurse or mid-level will be turned into a very comprehensive report that will be used by the physician to determine if follow-care is needed and/or how much care is required. Tell the patient that this is very focused care that will give them the best results for their personal plan of health.
How can a nurse be qualified to do the Annual Wellness Visit?
Remember that the wellness visit is a data gathering visit only. There is no diagnosing occurring during the wellness visit. The nurse (or other medical professional) is gathering information from the patient. That information is being analyzed by our partners and their proprietary health risk assessment (HRA) engine and the AWV report is produced for the physician. At that point, the physician begins problem-focused care, follow-up testing, etc that may lead to a diagnosis.
Do I need to schedule the patient for a follow-up visit?
We recommend that you tell the patient that if the risk factors are significant then you would like to have them come back in for follow-up care. That is completely up to the physician to make that call once he or she sees the AWV report.
Our core focus is the patient – improving quality of life through education and awareness. We believe that our wellness initiatives will enable you to grow practice profitability and support positive patient outcomes. We hope you will join us by participating in this worthwhile effort. We are thrilled to offer a program that will focus on the well being of your most valuable asset—your patients.