Medicare Preventive Services and Annual Wellness Visit Tricia

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Medicare Preventive Services and Annual Wellness Visit Tricia Marriott, PA-C, MPAS, DFAAPA Director, Reimbursement

Medicare Preventive Services and Annual Wellness Visit Tricia Marriott, PA-C, MPAS, DFAAPA Director, Reimbursement Advocacy tmarriott@aapa. org

@Tricia. PAC

@Tricia. PAC

Disclaimer • This presentation was current at the time it was submitted. It does

Disclaimer • This presentation was current at the time it was submitted. It does not represent payment or legal advice. • Medicare policy changes frequently, so be sure to keep current by going to www. cms. gov. • Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. • The American Medical Association has copyright and trademark protection of CPT ©.

Medicare Preventive Services: Terminology • “Welcome to Medicare” /Initial Preventive Physical Examination (IPPE) •

Medicare Preventive Services: Terminology • “Welcome to Medicare” /Initial Preventive Physical Examination (IPPE) • Annual Wellness Visit (AWV); Initial and Subsequent. • The Initial AWV is NOT the same as the IPPE! • Personalized Prevention Plan Services (PPPS) • Health Risk Assessment (HRA) • Preventive Services

INITIAL PREVENTIVE PHYSICAL EXAMINATION

INITIAL PREVENTIVE PHYSICAL EXAMINATION

Initial Preventive Physical Examination (IPPE) • Also known as the “Welcome to Medicare” Preventive

Initial Preventive Physical Examination (IPPE) • Also known as the “Welcome to Medicare” Preventive Visit • One-time visit • Covered within the first 12 months of Medicare Part B enrollment

Who Can Provide the IPPE? • Physician (doctor of medicine or osteopathy) • Qualified

Who Can Provide the IPPE? • Physician (doctor of medicine or osteopathy) • Qualified non-physician practitioner, which includes a: – Physician assistant – Nurse practitioner – Clinical nurse specialist

“Incident-to” billing • Does NOT apply to the IPPE • Claim must be submitted

“Incident-to” billing • Does NOT apply to the IPPE • Claim must be submitted under the NPI of the rendering provider (the PA). • Reimbursement will be at 85% of the physician fee schedule.

How to Code • Service Code G 0402 is used to report the IPPE

How to Code • Service Code G 0402 is used to report the IPPE • Location: Typically provided in the office setting. However, there are location identifiers for other settings that are allowed. • Diagnosis Code: there is no specific ICD-9 code. An “appropriate” ICD code should be chosen. An example of a possible code would be V 70. 0. V 70. 3, V 70. 9 (General Medical Examination…. )

Payment for G 0402 -Michigan Initial preventive physical examination; face-to-face visit, services limited to

Payment for G 0402 -Michigan Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment • Non-facility $150. 85 -$162. 63 • Facility $121. 32 -$129. 89 Source: CMS Physician Fee schedule Look-up/retrieved February 17, 2013

How Often? • IPPE (G 0402) is a one-time benefit. • MUST be provided

How Often? • IPPE (G 0402) is a one-time benefit. • MUST be provided within 12 months of effective date of Medicare beneficiary’s Part B coverage. • The screening EKG, when performed from an IPPE, is also only covered once in a beneficiary’s lifetime.

Coinsurance and Deductible • Effective January 1, 2011, waived for the IPPE (G 0402).

Coinsurance and Deductible • Effective January 1, 2011, waived for the IPPE (G 0402). • HOWEVER, the coinsurance and deductible still applies to the screening EKG.

The IPPE is a Preventive Visit and not a Routine Physical Examination • The

The IPPE is a Preventive Visit and not a Routine Physical Examination • The IPPE is a dedicated preventive visit where a beneficiary and their health care provider may discuss a beneficiary’s health status and maximize the preventive services that are available to Medicare beneficiaries • The IPPE is not a head to toe physical examination; however there are required elements. 42 CFR 410. 16

IPPE Required Elements: History 1. Review of the beneficiary’s medical and social history. At

IPPE Required Elements: History 1. Review of the beneficiary’s medical and social history. At a minimum, obtain the following: • Past medical/surgical history (experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments); • Current medications and supplements (including calcium and vitamins); • Family history (review of medical events in the • beneficiary’s family, including diseases that may be hereditary or place the beneficiary at risk); • History of alcohol, tobacco, and illicit drug use; • Diet; and • Physical activities.

IPPE Required Elements: History 2. Review of the beneficiary’s potential risk factors for depression

IPPE Required Elements: History 2. Review of the beneficiary’s potential risk factors for depression and other mood disorders Use any appropriate screening instrument for persons without a current diagnosis of depression recognized by national professional medical organizations to obtain current or past experiences with depression or other mood disorders.

IPPE Required Elements: History 3. Review of the beneficiary’s functional ability and level of

IPPE Required Elements: History 3. Review of the beneficiary’s functional ability and level of safety Use any appropriate screening questions or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the following areas: • Hearing impairment, • Activities of daily living, • Falls risk, and • Home safety.

IPPE Required Elements: Exam 4. An examination Obtain the following: • Height, weight, and

IPPE Required Elements: Exam 4. An examination Obtain the following: • Height, weight, and blood pressure; • Visual acuity screen; • Measurement of body mass index; and • Other factors deemed appropriate based on the • beneficiary’s medical and social history and current clinical standards.

IPPE Required Elements: Exam 5. End-of-life planning is a required service, upon the beneficiary’s

IPPE Required Elements: Exam 5. End-of-life planning is a required service, upon the beneficiary’s consent. End-of-life planning is verbal or written information provided to the beneficiary regarding: • The beneficiary’s ability to prepare an advance directive in the case that an injury or illness causes the beneficiary to be unable to make health care decisions, and • Whether or not the physician is willing to follow the beneficiary’s wishes as expressed in the advance directive.

IPPE Required Elements: Counseling 6. Education, counseling, and referral based on the previous five

IPPE Required Elements: Counseling 6. Education, counseling, and referral based on the previous five components Based on the results of the review and evaluation services provided in the previous five components, provide education, counseling, and referral as appropriate.

IPPE Required Elements: Counseling 7. Education, counseling, and referral for other preventive services Includes

IPPE Required Elements: Counseling 7. Education, counseling, and referral for other preventive services Includes a brief written plan, such as a checklist, to be given to the beneficiary for obtaining a screening electrocardiogram (EKG), as appropriate, and the appropriate screenings and other preventive services that are covered as separate Medicare Part B benefits.

Resources Quick Reference Information: The ABCs of Providing the Initial Preventive Physical Examination Medicare

Resources Quick Reference Information: The ABCs of Providing the Initial Preventive Physical Examination Medicare Learning Network® (MLN) Products http: //www. CMS. gov/MLNProducts/downloads/MPS_QRI_IPPE 001 a. pdf The Guide to Medicare Preventive Services, Chapter 1 http: //www. CMS. gov/MLNProducts/downloads/mps_guide_web 061305. pdf Claims Processing Manual Pub. 100 -04, Chapter 18, Section 80 http: //www. cms. gov/manuals/downloads/clm 104 c 18. pdf Chapter 12, Section 30. 6. 1. 1 http: //www. cms. gov/manuals/downloads/clm 104 c 12. pdf.

ANNUAL WELLNESS VISIT

ANNUAL WELLNESS VISIT

Annual Wellness Visit (AWV) • Beneficiary has had Part B for more than 12

Annual Wellness Visit (AWV) • Beneficiary has had Part B for more than 12 months. • Available once every 12 months. • If beneficiary had an IPPE/Welcome to Medicare visit, then they will be eligible for AWV 12 months following the IPPE.

Who Can Provide the AWV? A “health professional” meaning: – – – Physician assistant

Who Can Provide the AWV? A “health professional” meaning: – – – Physician assistant Nurse practitioner Clinical nurse specialist Medical professional (including health educator, RD, nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician. *Note: includes NPP!

The AWV is a Preventive Visit and not a Routine Physical Examination • The

The AWV is a Preventive Visit and not a Routine Physical Examination • The AWV is a yearly dedicated preventive visit where a beneficiary and their health care provider may discuss a beneficiary’s health status and maximize the preventive services that are available to Medicare beneficiaries • Like IPPE, the AWV is not a head to toe physical examination

“Incident-to” Billing • Does NOT apply to the AWV • Claim must be submitted

“Incident-to” Billing • Does NOT apply to the AWV • Claim must be submitted under the NPI of the rendering provider (the PA). • Reimbursement will be at 85% of the physician fee schedule

First Annual Wellness Visit • • Health risk assessment Medical/family history List of current

First Annual Wellness Visit • • Health risk assessment Medical/family history List of current providers/suppliers blood pressure, height, weight, and other routine measurements • Detection of any cognitive impairment • Review potential (risk factors) for depression, functional ability, and level of safety Establishment of: • Written screening schedule (such as a checklist) for the next 5 -10 years • List of risk factors and conditions where interventions recommended • Personalized health advice and referrals for health education and preventive counseling

Subsequent Annual Wellness Visit • • Updated health risk assessment Update of medical/family history

Subsequent Annual Wellness Visit • • Updated health risk assessment Update of medical/family history Update of list of current providers/suppliers blood pressure, weight, and other routine measurements Update to: • Written screening schedule • List of risk factors and conditions where interventions are recommended • Personalized health advice and referrals for health education and preventive counseling

Health Risk Assessment (HRA) • Collects self-reported information known to the beneficiary • Can

Health Risk Assessment (HRA) • Collects self-reported information known to the beneficiary • Can be administered by beneficiary or health professional before, or as part of, the annual wellness visit • Takes no more than 20 minutes to complete • Addresses the following topics: Demographic data Self assessment of health status Psychosocial risks Behavioral risks Activities of daily living and instrumental activities of daily living

How to Code Service Codes: • G 0438 (Annual wellness visit, including Personalized Prevention

How to Code Service Codes: • G 0438 (Annual wellness visit, including Personalized Prevention Plan Service (PPPS), first visit), and • G 0439 (Annual wellness visit, including PPPS, subsequent visit). Ø Diagnosis Code: there is no specific ICD-9 code. An “appropriate” ICD code should be chosen. An example of a possible code would be V 70. 0. V 70. 3, V 70. 9 (General Medical Examination…. )

Payment rates-Michigan • G 0438 (AWV, initial visit) Medicare Non-facility Payment $160. 59 -$173.

Payment rates-Michigan • G 0438 (AWV, initial visit) Medicare Non-facility Payment $160. 59 -$173. 42 • G 0439 (AWV, subsequent visit) Medicare Non-facility Payment $106. 50 -$114. 27 Source: CMS Physician Fee schedule Look-up/retrieved February 17, 2013

How Often? • First Visit (G 0438)-once in a lifetime • Subsequent visit (G

How Often? • First Visit (G 0438)-once in a lifetime • Subsequent visit (G 0439)-annually after 11 full months have passed since the last AWV

Coinsurance and Deductible • Effective for dates of services on or after January 1,

Coinsurance and Deductible • Effective for dates of services on or after January 1, 2011 • Copayment or coinsurance and the Medicare Part B deductible are waived for the AWV (G 0438 and G 0439)

Resources MLN Products Quick Reference Information: The ABCs of Providing the Annual Wellness Visit

Resources MLN Products Quick Reference Information: The ABCs of Providing the Annual Wellness Visit http: //www. CMS. gov/MLNProducts/downloads/A WV_Chart_ICN 905706. pdf MM 7079: Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS) http: //www. cms. gov/MLNMatters. Articles/downloa ds/MM 7079. pdf The Guide to Medicare Preventive Services, Chapter 4 http: //www. CMS. gov/MLNProducts/downloads/m ps_guide_web-061305. pdf

More Resources • For Health Professionals: MLNMatters Article http: //www. cms. gov/MLNMatters. Articles/Downloads/MM 7079.

More Resources • For Health Professionals: MLNMatters Article http: //www. cms. gov/MLNMatters. Articles/Downloads/MM 7079. pdf A Framework for Patient-Centered Health Risk Assessments (Centers for Disease Control and Prevention) http: //www. cdc. gov/policy/opth/hra • For Beneficiaries: General Preventive Services Resources http: //www. medicare. gov/navigation/manage-yourhealth/preventive-services/preventive-service-overview. aspx Your Guide to Medicare’s Preventive Services http: //www. medicare. gov/Publications/Pubs/pdf/10110. pdf

Covered Preventive Services Wait…. . What?

Covered Preventive Services Wait…. . What?

Covered Preventive Services IPPE and AWV are just part of the range of preventive

Covered Preventive Services IPPE and AWV are just part of the range of preventive services covered by Medicare.

Medicare Part B Preventive Services • Initial Preventive Physical Examination (IPPE) • Intensive Behavioral

Medicare Part B Preventive Services • Initial Preventive Physical Examination (IPPE) • Intensive Behavioral Therapy (IBT) for Obesity (effective November 29, 2011). • Bone Mass Measurements • Medical Nutrition Therapy (MNT) • Cardiovascular Screening Blood Tests Prostate Cancer Screening • Colorectal Cancer Screening Seasonal Influenza, Pneumococcal, and Hepatitis B Vaccinations and their Administration • Counseling to Prevent Tobacco Use for Asymptomatic Patients Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (effective October 14, 2011) • Diabetes Screening Tests • Screening for Depression in Adults (effective October 14, 2011)

Continued… • • • Diabetes Self-Management Training (DSMT) Screening Mammography Glaucoma Screening Pap Tests

Continued… • • • Diabetes Self-Management Training (DSMT) Screening Mammography Glaucoma Screening Pap Tests and Pelvic Examination Human Immunodeficiency Virus (HIV) Screening Sexually Transmitted Infections (STIs) Screening and High Intensity Behavioral Counseling (HIBC) to Prevent STIs (effective November 8, 2011) • IBT for Cardiovascular Disease (effective November 8, 2011) Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)

Covered Services • The Guide to Medicare Preventive Services http: //www. CMS. gov/MLNProducts/downloads/m ps_guide_web-061305.

Covered Services • The Guide to Medicare Preventive Services http: //www. CMS. gov/MLNProducts/downloads/m ps_guide_web-061305. pdf • MLN Preventive Services Products Page http: //www. cms. gov/MLNProducts/35_Preventiv e. Services. asp • The CMS Prevention Website http: //www. cms. gov/Prevntion. Gen. Info

Take Home • PAs are eligible providers; Service must be billed under the PA.

Take Home • PAs are eligible providers; Service must be billed under the PA. • There are great resources and job aids/charts to guide both the provider and the patient through the prevention services. • IDEAL issue for your local health fair: “Ask me about: Medicare’s Preventive Services”. “Have you had your screenings? ”

There’s an APP! • Multiple platforms and devices supported • From AHRQ-browse U. S.

There’s an APP! • Multiple platforms and devices supported • From AHRQ-browse U. S. Preventive Services Task Force (USPSTF) recommendations on the web or on your PDA or mobile device • http: //epss. ahrq. gov/PDA/index. jsp

AAPA Website • Summary that includes links to Medicare Resources and tables. • http:

AAPA Website • Summary that includes links to Medicare Resources and tables. • http: //www. aapa. org/uploaded. Files/content/Your _PA_Practice/Reimbursement/Resource_Items/ Medicare_Preventive_Services_2013. pdf Member Log-in required.

Bill one AWV and your CD is paid for! • Wellness Visits pay BIG

Bill one AWV and your CD is paid for! • Wellness Visits pay BIG dollars with minimum physician time- but only if you have the right workflow tools. Medicare patients will continue to take advantage of these important Annual Wellness Visits now that the health reform law is officially here to stay. • Ensure that your wellness visits are quick and efficient while complying with all Medicare requirements with the Annual Wellness Visit Encounter Tools. • This complete set of 3 comprehensive AWV encounter forms meets both CMS and CDC guidelines, so you're guaranteed a set of forms that are 100% up-to-date for use in 2013 and beyond. This single CD includes: • Initial AWV patient form (View a Sample Page) • Subsequent AWV patient form • Health Risk Assessment (HRA) form - Newest element of the AWV • The Annual Wellness Visit Encounter Tools help you: • Save time by having pre-developed forms that are comprehensive and require no additional elements • Optimize your AWV workflow to minimize physician time by having HRA forms your staff can use to prepare patients before they arrive • • Order Your CD Today! Price: $149 Copyright© 2013 Decision. Health®. All rights reserved.

2318 Mill Road, Suite 1300 Alexandria, Virginia 22314 P 703 -836 -2272 www. aapa.

2318 Mill Road, Suite 1300 Alexandria, Virginia 22314 P 703 -836 -2272 www. aapa. org