Wellness visits for Medicare patients

November 18th, 2013 - Codapedia Editor
Categories:   HCPCS Coding   Medicare   Preventive Medicine Service  
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Dec 20, 2010 Added Medicare's MLN Matters article as a resource.

Hold the champagne--it's true that Health Care Reform added an annual "wellness"visit for every beneficiary, but it's not what you or your doctors think of as an annual exam.  In fact, it's has more in common with the Welcome to Medicare visit than an annual.  The CPT® codes for preventive medicine (99381--99397) remain non-covered, routine services. Bill them to Medicare and they will be denied as patient due.  The Annual Wellness Visit (AWV) will be billed to Medicare with new HCPCS codes developed for this purpose.

First, during the first year a patient is enrolled in Medicare, the beneficiary will be eligible only for the Welcome to Medicare visit.  (See the Codapedia article on this topic.)  The Welcome to Medicare visit, or Initial Preventive Physical Exam, IPPE, is a once in a lifetime benefit, billed with HCPCS code G0402.  It includes a screening for depression, safety at home, ability to perform activities of daily living and a written checklist given to the patient with a recommendation to obtain Medicare covered preventive services.

The Annual Wellness Visits are defined as initial and subsequent.   These visits do not have new and established patient designations, so a clinician can perform an initial visit on an established patient to the practice. The initial AWV may be performed on patients who have been enrolled in Medicare for more than a year, or one year after the patient  had the Welcome to Medicare visit. A patient is eligible for the subsequent wellness visit one year after the initial wellness visit.  An example might help.

Bob is 70 and has been enrolled in Medicare since he was 65.  Starting January 1, 2011, Bob is eligible for an Initial Annual Wellness Visit.  Let's say he receives that on April 29, 2011.  He is eligible for a subsequent wellness visit one year later, April 30, 2012.

Jock, however, became eligible for Medicare on July 1, 2010.  He is eligible for the Welcome to Medicare visit until June 30, 2011.  Let's say he receives it on May 7, 2011.  He is eligible for his initial Annual Wellness Visit starting May 8, 2012, an for a subsequent wellness visit May 9, 2013.  

What about patients who receive part of their care in the sunny south during the winter (lucky ones) and part of their care in the north during the summer.  Can they receive the visits twice, once in the summer and once in the winter, since they are cared for by two different physicians?  No, these are per beneficiary, not per physician.

What it required during the initial Annual Wellness Visit?

  • Establish/update the patient's past medical, family and social history 
  •  List patient's current medical providers, suppliers and all medications, including supplements
  • Record height, weight, calculate BMI, BP and "other routine measurements"
  • Review potential for depression using an appropriate screening tool
  • Review individual's functional level of safety and ability to perform activities of daily living, fall risk and home safety
  • Voluntary advance care planning in the case that the patient is unable to make decisions in the future due to illness or injury--This was removed by CMS in early Jan. 2011
  • Detect cognitive impairment, via direct observation, discussion, review of medical records or discussion with family
  • Establish a personalized, written preventive plan for the next 5-10 years with services recommended by the US Preventive Task Force
  • Furnish personalized health advice that includes listing of patient's conditions. risk factors, treatment recommendations, and methods to decrease risk factors such as smoking, obesity, etc.

The subsequent annual wellness visit may not be billed in 2011, because in order to be eligible to receive that service, the patient must have received the initial Annual Wellness Visit, which does not become effective until 1-1-11.

There are two new HCPCS codes to describe these services:

G0438: Annual Wellness Visit (AWV) including personalized prevention plan services; first visit

Total RVUs of 4.74

G0439: Annual Wellness Visit (AWV) including personalized prevention plan services; subsequent visits

 

Watch for the CMS transmittals and MedLearn Matters article to be released at the end of 2010.

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