wellness visit rvu

Medicare Wellness Visits Back to MLN Print November 2023 Updates

What’s Changed?

• Added information about monthly chronic pain management and treatment services
• Added information about checking for cognitive impairment during annual wellness visits
• Added information about Social Determinants of Health Risk Assessments as an optional element of annual wellness visits

Quick Start

The Annual Wellness Visits video helps you understand these exams, as well as their purpose and claim submission requirements.

Medicare Physical Exam Coverage

Initial Preventive Physical Exam (IPPE)

Review of medical and social health history and preventive services education.

✔ New Medicare patients within 12 months of starting Part B coverage

✔ Patients pay nothing (if provider accepts assignment)

Annual Wellness Visit (AWV)

Visit to develop or update a personalized prevention plan and perform a health risk assessment.

✔ Covered once every 12 months

Routine Physical Exam

Exam performed without relationship to treatment or diagnosis of a specific illness, symptom, complaint, or injury.

✘ Medicare doesn’t cover a routine physical

✘ Patients pay 100% out-of-pocket

Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health :

• Health Equity Technical Assistance Program
• Disparities Impact Statement

Communication Avoids Confusion

As a health care provider, you may recommend that patients get services more often than we cover or that we don’t cover. If this happens, help patients understand they may have to pay some or all costs. Communication is key to ensuring patients understand why you’re recommending certain services and whether we cover them.

Initial Preventive Physical Exam

The initial preventive physical exam (IPPE), also known as the “Welcome to Medicare” preventive visit, promotes good health through disease prevention and detection. We pay for 1 IPPE per lifetime if it’s provided within the first 12 months after the patient’s Part B coverage starts.

1. Review the patient’s medical and social history

At a minimum, collect this information:

• Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments)
• Current medications, supplements, and other substances the person may be using
• Family history (review the patient’s family and medical events, including hereditary conditions that place them at increased risk)
• Physical activities
• Social activities and engagement
• Alcohol, tobacco, and illegal drug use history

Learn information about Medicare’s substance use disorder (SUD) services coverage .

2. Review the patient’s potential depression risk factors

Depression risk factors include:

• Current or past experiences with depression
• Other mood disorders

Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. APA’s Depression Assessment Instruments has more information.

3. Review the patient’s functional ability and safety level

Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the patient’s:

• Ability to perform activities of daily living (ADLs)
• Hearing impairment
• Home and community safety, including driving when appropriate

Medicare offers cognitive assessment and care plan services for patients who show signs of impairment.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), blood pressure, balance, and gait
• Visual acuity screen
• Other factors deemed appropriate based on medical and social history and current clinical standards

5. End-of-life planning, upon patient agreement

End-of-life planning is verbal or written information you (their physician or practitioner) can offer the patient about:

• Their ability to prepare an advance directive in case an injury or illness prevents them from making their own health care decisions
• If you agree to follow their advance directive
• This includes psychiatric advance directives

6. Review current opioid prescriptions

For a patient with a current opioid prescription:

• Review any potential opioid use disorder (OUD) risk factors
• Evaluate their pain severity and current treatment plan
• Provide information about non-opiod treatment options
• Refer to a specialist, as appropriate

The HHS Pain Management Best Practices Inter-Agency Task Force Report has more information. Medicare now covers monthly chronic pain management and treatment services .

7. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them to treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

8. Educate, counsel, and refer based on previous components

Based on the results of the review and evaluation services from the previous components, provide the patient with appropriate education, counseling, and referrals.

9. Educate, counsel, and refer for other preventive services

Include a brief written plan, like a checklist, for the patient to get:

• A once-in-a-lifetime screening electrocardiogram (ECG), as appropriate
• Appropriate screenings and other covered preventive services

Use these HCPCS codes to file IPPE and ECG screening claims:

Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment

Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv

* Section 60.2 of the Medicare Claims Processing Manual, Chapter 9 has more information on how to bill HCPCS code G0468.

Report a diagnosis code when submitting IPPE claims. We don’t require you to use a specific IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an IPPE when performed by a:

• Physician (doctor of medicine or osteopathy)
• Qualified non-physician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist)

When you provide an IPPE and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

CPT only copyright 2022 American Medical Association. All rights reserved.

IPPE Resources

• 42 CFR 410.16
• Section 30.6.1.1 of the Medicare Claims Processing Manual, Chapter 12
• Section 80 of the Medicare Claims Processing Manual, Chapter 18
• U.S. Preventive Services Task Force Recommendations

No. The IPPE isn’t a routine physical that some patients may get periodically from their physician or other qualified non-physician practitioner (NPP). The IPPE is an introduction to Medicare and covered benefits, and it focuses on health promotion, disease prevention, and detection to help patients stay well. We encourage providers to inform patients about the AWV during their IPPE. The Social Security Act explicitly prohibits Medicare coverage of routine physical exams.

No. The IPPE and AWV don’t include clinical lab tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.

No. We waive the coinsurance, copayment, and Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening electrocardiogram (ECG) (HCPCS codes G0403, G0404, or G0405).

A patient who hasn’t had an IPPE and whose Part B enrollment began in 2023 can get an IPPE in 2024 if it’s within 12 months of the patient’s Part B enrollment effective date.

We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, find your MAC’s website .

Annual Wellness Visit Health Risk Assessment

The annual wellness visit (AWV) includes a health risk assessment (HRA). View the HRA minimum elements summary below. A Framework for Patient-Centered Health Risk Assessments has more information, including a sample HRA.

Perform an HRA

• You or the patient can update the HRA before or during the AWV
• Consider the best way to communicate with underserved populations, people who speak different languages, people with varying health literacy, and people with disabilities
• Demographic data
• Health status self-assessment
• Psychosocial risks, including, but not limited to, depression, life satisfaction, stress, anger, loneliness or social isolation, pain, suicidality, and fatigue
• Behavioral risks, including, but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (for example, seat belt use), and home safety
• Activities of daily living (ADLs), including dressing, feeding, toileting, and grooming; physical ambulation, including balance or fall risks and bathing; and instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, transportation, shopping, managing medications, and handling finances

1. Establish the patient’s medical and family history

At a minimum, document:

• Medical events of the patient’s parents, siblings, and children, including hereditary conditions that place them at increased risk
• Use of, or exposure to, medications, supplements, and other substances the person may be using

2. Establish a current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure
• Other routine measurements deemed appropriate based on medical and family history

4. Detect any cognitive impairments the patient may have

Check for cognitive impairment as part of the first AWV.

Assess cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others. Consider using brief cognitive tests, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Alzheimer’s and Related Dementia Resources for Professionals has more information.

5. Review the patient’s potential depression risk factors

6. Review the patient’s functional ability and level of safety

• Ability to perform ADLs

7. Establish an appropriate patient written screening schedule

Base the written screening schedule on the:

• Checklist for the next 5–10 years
• United States Preventive Services Task Force and Advisory Committee on Immunization Practices (ACIP) recommendations
• Patient’s HRA, health status and screening history, and age-appropriate preventive services we cover

8. Establish the patient’s list of risk factors and conditions

• A recommendation for primary, secondary, or tertiary interventions or report whether they’re underway
• Mental health conditions, including depression, substance use disorders , suicidality, and cognitive impairments
• IPPE risk factors or identified conditions
• Treatment options and associated risks and benefits

9. Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs

Include referrals to educational and counseling services or programs aimed at:

• Fall prevention
• Physical activity
• Tobacco-use cessation
• Social engagement
• Weight loss

10. Provide advance care planning (ACP) services at the patient’s discretion

ACP is a discussion between you and the patient about:

• Preparing an advance directive in case an injury or illness prevents them from making their own health care decisions
• Future care decisions they might need or want to make
• How they can let others know about their care preferences
• Caregiver identification
• Advance directive elements, which may involve completing standard forms

Advance directive is a general term that refers to various documents, like a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. The Advance Care Planning fact sheet has more information.

We don’t limit how many times the patient can revisit the ACP during the year, but cost sharing applies outside the AWV.

11. Review current opioid prescriptions

• Review any potential OUD risk factors
• Provide information about non-opioid treatment options

12. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them for treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

13. Social Determinants of Health (SDOH) Risk Assessment

Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and ensure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate.

1. Review and update the HRA

2. Update the patient’s medical and family history

At a minimum, document updates to:

3. Update current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including those added because of the first AWV personalized prevention plan services (PPPS), and any behavioral health providers.

• Weight (or waist circumference, if appropriate) and blood pressure

5. Detect any cognitive impairments patients may have

Check for cognitive impairment as part of the subsequent AWV.

6. Update the patient’s written screening schedule

Base written screening schedule on the:

7. Update the patient’s list of risk factors and conditions

• Mental health conditions, including depression, substance use disorders , and cognitive impairments
• Risk factors or identified conditions

8. As necessary, provide and update patient PPPS, including personalized health advice and appropriate referrals to health education or preventive counseling services or programs

9. Provide advance care planning (ACP) services at the patient’s discretion

10. Review current opioid prescriptions

11. Screen for potential substance use disorders (SUDs)

12. Social Determinants of Health (SDOH) Risk Assessment

Preparing Eligible Patients for their AWV

Help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment:

• Medical records, including immunization records
• Detailed family health history
• Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
• Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists

Use these HCPCS codes to file AWV claims:

Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

Report a diagnosis code when submitting AWV claims. We don’t require you to use a specific AWV diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an AWV if performed by a:

• Medical professional (including health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of medical professionals directly supervised by a physician

When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV, and G0439 is for subsequent AWVs. Don’t bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. We deny these claims with messages indicating the patient reached the benefit maximum for the time period.

Medicare telehealth includes HCPCS codes G0438 and G0439.

ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a patient to discuss their health care wishes and medical treatment preferences if they become unable to communicate or make decisions about their care. At the patient’s discretion, you can provide the ACP during the AWV.

Use these CPT codes to file ACP claims as an optional AWV element:

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Report a diagnosis code when submitting an ACP claim as an optional AWV element. We don’t require you to use a specific ACP diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

We waive both the Part B ACP coinsurance and deductible when it’s:

• Provided on the same day as the covered AWV
• Provided by the same provider as the covered AWV
• Billed with modifier 33 (Preventive Service)
• Billed on the same claim as the AWV

We waive the ACP deductible and coinsurance once per year when billed with the AWV. If we deny the AWV billed with ACP for exceeding the once-per-year limit, we’ll apply the ACP deductible and coinsurance .

We apply the deductible and coinsurance when you deliver the ACP outside the covered AWV. There are no limits on the number of times you can report ACP for a certain patient in a certain period. When billing this service multiple times, document changes in the patient’s health status or wishes about their end-of-life care.

SDOH is important in assessing patient histories; in assessing patient risk; and in guiding medical decision making, prevention, diagnosis, care, and treatment. In the CY 2024 Medicare Physician Fee Schedule final rule , we added a new SDOH Risk Assessment as an optional, additional element of the AWV. At both yours and the patient’s discretion, you may conduct the SDOH Risk Assessment during the AWV.

Use this HCPCS code to file SDOH Risk Assessment claims as an optional AWV element:

Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes

Report a diagnosis code when submitting an SDOH Risk Assessment claim as an optional AWV element. We don’t require you to use a specific SDOH Risk Assessment diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

The implementation date for SDOH Risk Assessment claims is July 1, 2024. We waive both the Part B SDOH Risk Assessment coinsurance and deductible when it’s:

We waive the SDOH Risk Assessment deductible and coinsurance once per year when billed with the AWV.

If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when you deliver the SDOH Risk Assessment outside the covered AWV.

AWV Resources

• 42 CFR 410.15
• Section 140 of the Medicare Claims Processing Manual, Chapter 18

No. The AWV isn’t a routine physical some patients may get periodically from their physician or other qualified NPP. We don’t cover routine physical exams.

No. We waive the coinsurance, copayment, and Part B deductible for the AWV.

We cover an AWV for all patients who’ve had Medicare coverage for longer than 12 months after their first Part B eligibility date and who didn’t have an IPPE or AWV within those past 12 months. We cover only 1 IPPE per patient per lifetime and 1 additional AWV every 12 months after the date of the patient’s last AWV (or IPPE). Check eligibility to find when a patient is eligible for their next preventive service.

Generally, you may provide other medically necessary services on the same date as an AWV. The deductible and coinsurance or copayment applies for these other medically necessary and reasonable services.

You have different options for accessing AWV eligibility information depending on where you practice. Check eligibility to find when a patient is eligible for their next preventive service. Find your MAC’s website if you have specific patient eligibility questions.

Know the Differences

An IPPE is a review of a patient’s medical and social health history and includes education about other preventive services .

• We cover 1 IPPE per lifetime for patients within the first 12 months after their Part B benefits eligibility date
• We pay IPPE costs if the provider accepts assignment

An AWV is a review of a patient’s personalized prevention plan of services and includes a health risk assessment.

• We cover an annual AWV for patients who aren’t within the first 12 months after their Part B benefits eligibility date
• We cover an annual AWV 12 months after the last AWV’s (or IPPE’s) date of service
• We pay AWV costs if the provider accepts assignment

A routine physical is an exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.

• We don’t cover routine physical exams, but the IPPE, AWV, or other Medicare benefits cover some routine physical elements
• Patients pay 100% out of pocket

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CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

• Center on Health Equity and Access
• Health Care Cost
• Health Care Delivery
• Value-Based Care

Increasing Medicare Annual Wellness Visits in Accountable Care Organizations

• Karen Shakiba, BS
• Jacob Heidbrink, MS
• Megan Guinn, MBA, BSN, RN

Through innovations increasing the ease of scheduling and the efficiency of conducting annual wellness visits (AWVs), a large Medicare accountable care organization has been able to increase AWV rates among eligible beneficiaries.

Medicare’s annual wellness visit (AWV) was introduced in 2011 as an opportunity for providers to focus on aspects of preventive care for eligible beneficiaries. Despite potential incentives for doing so, adoption of the AWV has been slow, which may be contributing to a relative paucity of data evaluating how conducting AWVs affects patient outcomes and health care spending. In this article, we discuss how a large Medicare accountable care organization implemented several innovations aimed at decreasing barriers to scheduling and increasing the efficiency and convenience of conducting AWVs, which led to a substantial increase in AWV rates within 12 months. This manuscript provides a conceptual analysis assessing the potential benefits and costs of implementing the AWV and subsequently details the innovations and the effects of these innovations on AWV rates among attributed patients.

Am J Accountable Care. 2021;9(3):13-18. https://doi.org/10.37765/ajac.2021.88749

In 2011, Medicare introduced the annual wellness visit (AWV) to expand coverage of preventive health services to older adults. The visit provides an opportunity for providers to focus on aspects of preventive care (eg, evidence-based screening services, personalized health risk assessments, advance care planning) that may often be overlooked during acute problem–based visits because of time constraints or more pressing health concerns. For AWVs, patients owe no co-pay and clinicians are reimbursed at a high rate. 1

CMS requires that certain elements be addressed at each AWV. Patients and providers work to create a personalized prevention plan, which includes age-appropriate preventive services, cognitive screening, personalized health advice to identify and work to mitigate risk factors, and the implementation of recommendations from the US Preventive Services Task Force and the Advisory Committee on Immunization Practices. 2 Ideally, the AWV affords the opportunity for early disease detection and downstream mitigation of disease effects, improving patient outcomes and lowering overall costs.

Although the overall utility of annual preventive visits in achieving these aims has been debated, 3 the relatively recent adoption of the AWV renders any definitive conclusions regarding its effectiveness premature. Some studies have shown associations between the AWV and increased utilization of preventive care services. One study indicated that the AWV is associated with significantly higher odds of undergoing mammography, Pap tests, bone mass measurement, and prostate and colon cancer screening, as well as obtaining the influenza vaccine. 4 Another study showed that patients who had an AWV had increased testing for possible causes of cognitive impairment (eg, thyrotropin, B12) relative to those without an AWV. 5 Additional work has demonstrated that Medicare beneficiaries who utilize AWVs have higher pneumococcal vaccination and influenza vaccination rates than those who do not, 6 and another study similarly demonstrated that patients who had an AWV had a higher percentage of influenza vaccination, depression screening, and sexually transmitted infection screening than those who did not. 7 However, one study suggested that depression screening was low (10%) among patients who receive AWVs and was not significantly different from those with non-AWV visits. 8

Although studies have shown increases in utilization of certain preventive services among AWV attendees, few studies have assessed the effects of the AWV on costs, and the existing studies show mixed results. One study demonstrated that a first-time AWV was associated with a 5.7% reduction in total health care costs in the 11 months following the AWV, estimating a per-member per-month decrease of $81 in overall spending. 9 Of note, patients in the highest-risk hierarchical condition category (HCC) quartile had the greatest reduction in costs for those attending an AWV relative to those who did not. Another study showed that AWV users had a significant reduction in total health care spending ($162) at 24 months following an AWV relative to matched beneficiaries who did not receive an AWV, 10 and a case report noted that increasing the percentage of its patients attending an AWV was associated with overall reductions in health care costs. 11 However, another large study comparing outcomes in practices that adopted the AWV vs those that did not found no consistent evidence of associations between AWV use and spending, emergency department visits, or hospitalizations. 3 Another study found that AWV rates were not correlated with Medicare spending. 12

Nevertheless, the prospect of eventually realizing decreases in health care costs by prioritizing preventive health has led Medicare to incentivize practices to incorporate the AWV, resulting in opportunities for accountable care organizations (ACOs) to increase revenue while providing this service to patients. Medicare covers AWVs at 100%, attributing 2.43 relative value units (RVUs) for initial AWVs and 1.5 RVUs for subsequent AWVs 13 ; additionally, providers are able to bill for diagnostic and treatment services provided at the same time as the AWV, often resulting in greater revenue for those practices utilizing the AWV (although these additional services may require a patient co-pay). 14,15 The mandated structure of the visit also helps physicians to close pay-for-performance quality measure gaps, and ACOs participating in the Medicare Shared Savings Program can satisfy quality measures using data collected at the AWV. 16 The visit also provides the opportunity to ensure the accuracy of HCC-related diagnoses, which may result in higher risk-adjusted factor scores and associated higher reimbursement rates for more complicated, at-risk patients. The AWV also provides an additional patient care visit, which may improve the stability of the beneficiary assignment to the practice conducting the visit. 14 As may be expected given these possible benefits, patients who are attributed to an ACO have been shown to be more likely to receive an AWV than those who are not. 12

Despite the possible benefits to both providers and patients, adoption of the AWV has been modest, with an estimated 24% of eligible beneficiaries receiving an AWV in 2017, 10 up from 7.5% in 2011. 12 The large proportion of eligible beneficiaries not receiving an AWV presents an opportunity to increase the evidence-based preventive care services provided to patients and realize additional revenue. Not many studies exist exploring the effects of interventions aimed at increasing the proportion of beneficiaries receiving an AWV. A case study of Bellin Health Partners described a 4-pronged approach utilizing a structured care team (registered nurse–led AWVs), health information technology applications (including work lists, compliance reports, and care gap reports), provider incentives, and staff communication (contacting beneficiaries to schedule visits), which ultimately led to an increase in the rate of AWVs among eligible beneficiaries. 11 Aledade similarly implemented training sessions and automated work lists to help small practices engage AWV-eligible beneficiaries. 17 A small university-affiliated practice utilized a nursing care manager, in concert with specific physician recommendations, to increase the rate of AWVs among eligible patients. 18 A 2008 systematic review examined the effects of various clinician interventions (computer-generated prompts and paper-based prompts) and patient interventions (including mailed reminder letters, telephone notifications, flyers and posters directed toward patients, home visitations encouraging vaccinations, and education to encourage return visits) on increasing use of preventive care services. Although it was conducted prior to the implementation of AWVs, the study demonstrated overall modest effects of utilizing prompts on increased utilization of preventive services, showing average differences of 10% to 14%, depending on the prompting method. 19

BJC is an integrated health system that operates a Medicare Shared Savings Program ACO, with roughly 150 primary care providers caring for 34,728 beneficiaries in Illinois and Missouri. BJC identified the AWV as a key opportunity to improve care delivery and sought to increase the rates at which its attributed eligible beneficiaries received AWVs. BJC identified 2 broad areas on which to focus its attention: decreasing barriers to scheduling AWVs and increasing the efficiency and convenience of conducting AWVs. BJC identified obstacles within both categories and implemented the innovations outlined within the following sections.

Increasing Ease of Scheduling AWVs

C-SNAP access for offices. C-SNAP is a service provided by CMS that allows providers and office staff to view eligibility and claim status information for Medicare beneficiaries. Medicare covers 1 AWV within each 12-month period for eligible beneficiaries. Given that other providers (including, at times, wellness vans 20 ) may have already conducted an AWV within the prior 12-month period, BJC providers may not know whether the AWV that they provide would be covered. BJC identified this uncertainty regarding whether beneficiaries had already obtained an AWV as a possible barrier to providing AWVs. C-SNAP allows users to review whether beneficiaries have had an AWV conducted with a provider outside the BJC system. BJC provided C-SNAP access for every office to facilitate reviews of claims for beneficiaries and ensure that the AWV is not duplicated.

Electronic health record tracking. BJC utilizes the Epic electronic health record (EHR), which allows for identification and tracking of pertinent health maintenance data. BJC ACO and information technology staff worked together to add a feature to each patient’s chart listing the date of the patient’s last AWV and the date that the patient would be eligible for their next AWV. This was viewable by providers and office staff to assist in scheduling patients for AWVs and identifying patients who presented to clinic for an acute visit who were also eligible for a concurrent AWV.

Eligible patient lists. ACO staff created a claims database of all ACO members indicating the date of the members’ most recent AWV (if any) and the date they were eligible for their next AWV. Individual patient lists were sent to each primary care clinic, and each clinic proactively contacted patients who were not yet scheduled for an AWV in the upcoming year. If patients were already scheduled (for a diabetes follow-up visit, for example), clinic staff would reach out to the patient regarding the possibility of adding an AWV at the same visit. Although significant manual efforts were still required, this intervention provided clarity regarding which patients were eligible for AWVs and ensured that they were scheduled at appropriate times to limit claim denials.

AWV tracking dashboard. BJC developed dashboards allowing for the visualization of AWV rates by provider, practice, and region. These dashboards allowed ACO leadership to analyze trends and allocate resources as needed (eg, more attention might be given to regions with low AWV rates, and providers with higher AWV rates might be able to offer additional feedback on effective methods).

Compensation bonus. To incentivize providers to address remaining barriers to scheduling and conducting AWVs, BJC approved a 1% compensation bonus for any primary care provider who achieved an AWV rate of 50% or greater among eligible ACO beneficiaries within the provider’s patient panel. To help providers monitor their progress, they were given updated AWV rates each month.

Increasing Efficiency and Convenience of Conducting AWVs

BJC incorporated the requirements of the AWV into a standardized note template in the Epic EHR to facilitate efficient entry of pertinent patient health information and reduce burden on clinicians. As has been demonstrated in other patient populations, patients who receive care at BJC often had a lack of clarity and understanding regarding the purpose and contents of the AWV. BJC therefore created a written communication ( eAppendix [ available at ajmc.com ]) to explain the purpose and contents of an AWV to patients and answer frequently asked questions.

BJC also sought to further streamline visits by beginning data acquisition prior to the visit. A portion of the AWV involves the completion of the health risk assessment (HRA) questionnaire. To facilitate the efficient collection of this information, BJC staff can send the HRA questionnaire to the patient before the visit through a patient portal; if the patient completes this before the visit, their responses will automatically populate the provider note.

To lay a consistent organizational groundwork, BJC additionally invested in webinar training sessions to further educate staff and providers on the purpose, content, and best practices of an AWV. BJC further developed and disseminated a best-practice workflow among providers to standardize elements of the AWV and give providers a consistent framework for conducting the visit. BJC also held in-person meetings with all member practices to communicate pertinent background information regarding the AWV, explain the interventions addressed herein, and provide the opportunity for providers to ask questions and offer feedback.

In 2018, BJC conducted AWVs for 44.3% of eligible attributed patients. BJC set a goal of conducting an AWV for 50% of eligible attributed beneficiaries in 2019 following the implementation of these interventions. BJC was able to exceed its goal, conducting AWVs for 69.7% of eligible patients in 2019. This places BJC above the 90th percentile among ACOs participating in the Medicare Shared Savings Program ( Figure ) (Institute for Accountable Care, email communication, analysis of 2019 Medicare claims data for 517 MSSP ACOs, March 19, 2021).

In total, of the 129 primary care providers who have at least 50 eligible beneficiaries within the BJC ACO network, 112 met the individual goal of providing AWVs to at least 50% of eligible patients within the provider’s patient panel. This equates to a total of 86.7% of providers meeting the established target.

Because the overall rate of AWVs has been increasing at the national level from the inception of the AWV through 2017, it is difficult to ascertain the portion of the year-over-year increase in AWVs across BJC that is attributable to the interventions discussed in this article. However, the magnitude of the increase (an absolute increase of 27% in AWV rates, or a relative year-over-year increase of 63%) suggests that the innovations were associated with benefits. Similar efforts to increase AWV rates at Bellin Health Partners yielded an increase from 43% of ACO-aligned beneficiaries having an AWV to 58% in the first year following the implementation of its innovations, and a further increase to 68% in the second year. 11

BJC did not specify which provider needed to conduct the AWV; thus, AWVs may have been carried out by physicians, nurse practitioners, or physician assistants. Furthermore, different portions of the AWVs may have been conducted by different members of the team.

Although AWVs are designed to address preventive health and in theory should yield benefits in the setting of adequate time horizons, the overall utility of well-visit checkups in reducing mortality and improving outcomes has not been definitively demonstrated 21 and has long been a subject of debate. Another study examining the association of the AWV with health care quality, costs, and utilization demonstrated cost reductions associated with the AWV and suggested that the greatest reductions in costs were achieved in the highest-risk segment of the population (using patient HCC calculations for risk stratification). 9 This may suggest that the allocation of resources toward higher-risk patients may yield proportionally greater returns on investment. Unfortunately, practices caring for higher-risk patients offer fewer AWVs, possibly as a consequence of resource limitations. 14 Utilization of the AWV has also been shown to vary by ethnoracial group (which the pertinent study defined as the social identification of a beneficiary based on their ethnicity, social background, and culture), with disparities largely explained by differences in income and education. 22,23

Limitations

To date, there have been few peer-reviewed studies that have explored the associations of the AWV with cost savings. Existing studies have analyzed cost impacts over a time horizon of no more than 24 months. Given the nature of the preventive measures included in the AWV, longer time frames may be necessary to more adequately evaluate the impact of the AWV on cost reductions and improvements in outcomes.

Additionally, as AWV rates are slowly increasing nationwide, a portion of the increases in AWVs may be attributable to external factors favoring the adoption of AWVs independent of the interventions adopted.

The identification and implementation of the AWV initiative required time and resources; although BJC did achieve its AWV goal, it is difficult to assess whether the associated focus on preventive health and increased revenue has, to date, ultimately provided value in keeping with the magnitude of the investment. This question may be better assessed as subsequent years demonstrate the durability of the improvements seen in AWV rates. If patients and providers perceive the AWV to be valuable and the efforts of BJC to decrease barriers to conducting the AWV are well received, AWV rates will remain high and the increases in revenue will continue to yield returns on the up-front investments.

Finally, BJC did not conduct formal data collection to directly assess patient or provider satisfaction with AWVs and the changes discussed herein. Accordingly, although the innovations were associated with a short-term increase in the rate of AWVs among eligible patients, impacts on patient perspectives and patient-provider relationships cannot be assessed presently.

Future Directions

Given the demonstration of the potential for the AWV to reduce health care spending for higher-risk patients, both patients and practices may benefit from the application of resources toward addressing barriers that may prevent patients (especially those who are older and frailer) from attending their AWV, including transportation and technological solutions. Previous association between HCC score and the magnitude of cost benefit from AWVs highlights the importance of continuing to monitor costs and quality measures for patients in the coming years. Future data may suggest that AWVs may be particularly important for a certain subset of patients, and greater resources and incentives may be dedicated to delivering AWVs to those patients who stand to derive the greatest benefit.

Given that a physical exam is not required for completion of an AWV, a telehealth visit may be an effective way of administering the visit. Patients could be provided blood pressure cuffs and scales, as necessary, to facilitate the body mass index calculation and blood pressure measurement required by an AWV. Some providers are already conducting AWVs via telehealth; additional consideration may be given to this possibility pending further guidance from CMS, especially as telehealth solutions continue to gain traction among patients and providers.

Assessing patient perspectives and satisfaction may also provide valuable insight. Patient satisfaction scores could be compared to assess whether certain aspects of the AWV are associated with greater satisfaction; for example, whether mode of delivery (in person or telehealth), the provider conducting the visit (eg, nurse, pharmacist, physician), length of visit, or whether the patient is co-billed for acute problems may affect the patient’s perspective and perceived utility of the AWV.

CONCLUSIONS

ACOs strive to provide patients with the proper care at the right time while reducing unnecessary costs and services. AWVs represent tremendous opportunities for ACOs to move toward meeting these objectives for patients. Efforts by BJC to increase the uptake of AWVs focused broadly on increasing the ease of scheduling AWVs and improving the efficiency and convenience of conducting an AWV. These efforts included increased communication, organizational support, and technological innovations, and they were associated with significant increases in AWVs in the first year following implementation. In the coming years, BJC will continue to monitor AWV rates to evaluate the durability of the improvements from the implemented changes and seek to assess effects on costs and the quality of care associated with the provision of the AWV.

Acknowledgments

The authors are tremendously grateful for the contributions of Nancy Patterson, Ashley Barton, Ryan Soluade, Ly Mettlach, Sunil Sinha, and Doug Pogue, without whose diligence and efforts the work presented herein would not have been possible.

Author Affiliations: BJC Healthcare Accountable Care Organization (NM, KS, JH, MG), St Louis, MO; Washington University School of Medicine in St Louis and Barnes-Jewish Hospital (NK), St Louis, MO.

Source of Funding : None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (NM, NK, KS, JH, MG); acquisition of data (NK, KS, JH); analysis and interpretation of data (NM); drafting of the manuscript (NM, NK); critical revision of the manuscript for important intellectual content (NM); administrative, technical, or logistic support (KS, JH, MG); and supervision (NM, MG).

Send Correspondence to: Nathan Moore, MD, BJC Healthcare Accountable Care Organization, 670 Mason Ridge Center Dr, Ste 300, St Louis, MO 63141. Email: [email protected].

1. Colburn JL, Nothelle S. The Medicare annual wellness visit. Clin Geriatr Med . 2018;34(1):1-10. doi:10.1016/j.cger.2017.09.001

2. Cuenca AE, Kapsner S. Medicare wellness visits: reassessing their value to your patients and your practice. Fam Pract Manag . 2019;26(2):25-30.

3. Ganguli I, Souza J, McWilliams JM, Mehrotra A. Association of Medicare’s annual wellness visit with cancer screening, referrals, utilization, and spending. Health Aff (Millwood) . 2019;38(11):1927-1935. doi:10.1377/hlthaff.2019.00304

4. Jiang M, Hughes DR, Wang W. The effect of Medicare’s annual wellness visit on preventive care for the elderly. Prev Med . 2018;116:126-133. doi:10.1016/j.ypmed.2018.08.035

5. Fowler NR, Campbell NL, Pohl GM, et al. One-year effect of the Medicare annual wellness visit on detection of cognitive impairment: a cohort study. J Am Geriatr Soc . 2018;66(5):969-975. doi:10.1111/jgs.15330

6. Shen AK, Warnock R, Kelman JA. Driving immunization through the Medicare annual wellness visit: a growing opportunity. Vaccine . 2017;35(50):6938-6940. doi:10.1016/ j.vaccine.2017.10.055

7. Tao G. Utilization pattern of other preventive services during the US Medicare annual wellness visit. Prev Med Rep . 2017;10:210-211. doi:10.1016/j.pmedr.2017.12.014

8. Pfoh E, Mojtabai R, Bailey J, Weiner JP, Dy SM. Impact of Medicare annual wellness visits on uptake of depression screening. Psychiatr Serv . 2015;66(11):1207-1212. doi:10.1176/appi.ps.201400524

9. Beckman AL, Becerra AZ, Marcus A, et al. Medicare annual wellness visit association with healthcare quality and costs. Am J Manag Care . 2019;25(3):e76-e82.

10. Misra A, Lloyd JT. Hospital utilization and expenditures among a nationally representative sample of Medicare fee-for-service beneficiaries 2 years after receipt of an annual wellness visit. Prev Med . 2019;129:105850. doi:10.1016/ j.ypmed.2019.105850

11. Graves N. The evolution of annual wellness visits at Bellin Health Partners next generation accountable care organization. CMS Innovation Center. May 2018. Accessed August 31, 2020. https://innovation.cms.gov/files/x/aco-casestudy-bellin.pdf

12. Ganguli I, Souza J, McWilliams JM, Mehrotra A. Trends in use of the US Medicare annual wellness visit, 2011-2014. JAMA . 2017;317(21):2233-2235. doi:10.1001/jama.2017.4342

13. Search the Physician Fee Schedule. CMS. Accessed September 1, 2020. https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

14. Ganguli I, Souza J, McWilliams JM, Mehrotra A. Practices caring for the underserved are less likely to adopt Medicare’s annual wellness visit. Health Aff (Millwood) . 2018;37(2):283-291. doi:10.1377/hlthaff.2017.1130

15. Feifer R, Torontow J, Shah K, Fields R. Leveraging annual wellness visits to drive ACO performance. Presented at: NAACOS Fall 2019 Conference; September 27, 2019; Washington, DC.

16. Medicare Shared Savings Program: quality measure benchmarks for the 2018 reporting year: guidance document. CMS. July 2019. Accessed September 1, 2020. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2018-and-2019-quality-benchmarks-guidance.pdf

17. Powers BW, Mostashari F, Maxson E, Lynch K, Navathe AS. Engaging small independent practices in value-based payment: building Aledade’s Medicare ACOs. Healthc (Amst) . 2018;6(1):79-87. doi:10.1016/j.hjdsi.2017.06.003

18. Bluestein D, Diduk-Smith R, Jordan L, Persaud K, Hughes T. Medicare annual wellness visits: how to get patients and physicians on board. Fam Pract Manag . 2017;24(2):12-16.

19. Dexheimer JW, Talbot TR, Sanders DL, Rosenbloom ST, Aronsky D. Prompting clinicians about preventive care measures: a systematic review of randomized controlled trials. J Am Med Inform Assoc . 2008;15(3):311-320. doi:10.1197/jamia.M2555

20. Hollmann P. The Medicare annual wellness visit: challenges and opportunities in practice. Public Policy Aging Rep . 2018;29(1):5-7. doi:10.1093/ppar/pry049

21. Krogsbøll LT, Jørgensen KJ, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database Syst Rev . 2019;1(1):CD009009. doi:10.1002/14651858.CD009009.pub3

22. Lind KE, Hildreth K, Lindrooth R, Crane LA, Morrato E, Perraillon MC. Ethnoracial disparities in Medicare annual wellness visit utilization: evidence from a nationally representative database. Med Care . 2018;56(9):761-766. doi:10.1097/MLR.0000000000000962

23. Lind KE, Hildreth KL, Perraillon MC. Persistent disparities in Medicare’s annual wellness visit utilization. Med Care . 2019;57(12):984-989. doi:10.1097/MLR.0000000000001229

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IMPLEMENTING A NURSE RUN ANNUAL WELLNESS VISIT

Dartmouth-Hithcock Medical Center, Grantham, New Hampshire, United States

The Medicare Annual Wellness Visit (AWV) is a free service offered to Medicare Part B beneficiaries annually to promote preventive care and reduce unnecessary utilization of health care services. The Centers for Medicare Services allows registered nurses to conduct the AWV and generate similar revenue to when a physician conducts the visit. Through the Northern New England Geriatric Workforce Enhancement Program (GWEP), we engaged twelve practices to implement the AWV as a nurse run visit. By implementing the nurse run AWV, a practice could increase utilization of AWV, increase employee and patient satisfaction, and increase revenue. One site was able to increase billing (non-facility price) by 212% and Relative Value Units (RVU) by 190% by implementing the Nurse Run AWV.

How to Get More Out of the Medicare Annual Wellness Visit

Are you taking advantage of Medicare’s free Annual Wellness Visit (AWV)? The AWV allows you and your provider to focus on key areas for staying well: disease prevention and detection and health promotion.

If you’re new to the AWV, you may have questions about what it includes and how we can further meet your needs.

What does the Annual Wellness Visit include?

“An AWV is a tool clinicians use to assess a patient’s overall health,” says Summit Health Vice-Chair of Primary Care in New Jersey, Jill Hup, MD . “It is meant to measure how well a patient can perform their daily activities and help keep them up to date with preventative screenings and vaccinations.”

Your AWV may include:

• A review of your medical, surgical, and family history
• Measurements of your height, weight, and blood pressure
• Assessments for depression, fall risk, and memory problems
• A review of your prescriptions and over-the-counter drugs for possible interactions
• Recommendations for immunizations, such as the flu or pneumonia shots, and health screenings for cancer, such as colonoscopy or mammogram
• A written preventive plan that outlines next steps for continued wellness
• Advance care planning as appropriate

Medicare covers one AWV a year, so schedule accordingly. For example, if you schedule an AWV in May of this year, the soonest you can come in for your next one would be May of next year.

Doesn’t my provider review my medical history, measurements, and prescriptions during my other visits?

Yes, your provider reviews this information at every visit; however, the AWV goes further.

The AWV allows time to assess your overall health and wellness holistically. This means that in addition to regularly reviewed information, your provider works with you to develop a wellness plan inclusive of all your screenings, immunizations, risk factors, personal history, and other preventive recommendations.

The reason that Medicare recommends the AWV is because it has been proven to keep patients healthy. Patients within our group who have AWVs every year complete more of their recommended screenings. They also have better control of their chronic conditions and fewer subsequent illnesses.

Does the AWV include a physical exam?

While the AWV is a valuable component of preventive care, it does not include a physical exam or address active medical problems. “We know this general view of wellness does not tell the whole story,” notes Dr. Hup. “Many of our patients live with chronic medical conditions like hypertension, diabetes, obesity, and depression that require close monitoring. Therefore, we offer a  Comprehensive Care Visit (CCV)  to ensure all medical issues are addressed at the time of the AWV. We want to educate patients about their disease, recommend treatment strategies to get their condition under good control, and provide encouragement and guidance along the way to enable them to live their very best life,” she adds.

A CCV includes all the AWV’s preventive services plus:

• A physical exam
• Management of acute and/or chronic conditions, including back pain, allergies, difficulty sleeping, mental health concerns, diabetes, high blood pressure, arthritis, or heart palpitations
• Referrals for laboratory or imaging tests as needed
• Follow-up with a specialty physician if required

Incorporating a CCV into your health care is a good idea, even if you’ve had a physical exam in the past.

“In primary care throughout Westmed Medical Group and Summit Health, we believe in providing comprehensive, lifelong care for patients,” says  Nicholas L. Pantaleo, MD , Chief of Internal Medicine at Westmed Medical Group, a Summit Health Company. “Therefore, if you are having any additional issues such as joint pain or are in need of blood pressure monitoring—even though this is not covered with the AWV—our providers will gladly address these new or chronic care concerns and even perform a physical exam.”

When you add a CCV to the AWV, you are only responsible for a copayment or coinsurance like any other visit to the doctor. Some Medicare Advantage plans cover a physical exam and the AWV.

I’ve been asked to come in for a blood draw before my AWV or CCV. Will it be covered?

The AWV does not include routine blood tests; however, to save you time and offer more comprehensive care, your provider may combine the AWV with your routine follow-up visit and may request blood tests. Lab tests are covered under your Medicare benefits based on the medical diagnosis associated with the orders. A patient may be responsible for the copayment/coinsurance as with other tests.  

Primary care is essential to better overall health

Primary care providers are the cornerstones of patient care, particularly in adults age 65 and older. Research shows that people who have an ongoing relationship with a primary care provider and get their recommended screenings and immunizations have better overall health and lower mortality rates.

“We strongly believe in caring for the whole person and in addressing all of your health care needs, including acute issues, and chronic conditions,” says internal medicine physician and Chief Quality Officer  Ashish Parikh, MD . “Preventive medicine saves lives. “Even if you’re in generally good health for someone over 65, you may not realize that your blood pressure is high, a medication has an interaction, or you are overdue for an eye exam. That’s why we encourage all our Medicare patients to make sure they have their AWV every year, whether they see their providers only once a year or come in often for follow-up visits.” 

If your primary care physician isn’t available when you want to come in for an AWV, another provider can step in to keep you on track. All our providers use a shared medical record system, so your primary care physician will be able to access information after your visit. The provider who covered your visit will communicate any recommendations, as well.

If you do not have a primary care provider, we will  find one for you .  

Yearly "Wellness" visits

If you’ve had Medicare Part B (Medical Insurance) for longer than 12 months, you can get a yearly “Wellness” visit to develop or update your personalized plan to help prevent disease or disability, based on your current health and risk factors. The yearly “Wellness” visit isn’t a physical exam.

Your first yearly “Wellness” visit can’t take place within 12 months of your Part B enrollment or your “Welcome to Medicare” preventive visit. However, you don’t need to have had a “Welcome to Medicare” preventive visit to qualify for a yearly “Wellness” visit.

Your costs in Original Medicare

You pay nothing for this visit if your doctor or other health care provider accepts assignment .

The Part B deductible  doesn’t apply. 

However, you may have to pay coinsurance , and the Part B deductible may apply if your doctor or other health care provider performs additional tests or services during the same visit that Medicare doesn't cover under this preventive benefit.

If Medicare doesn't cover the additional tests or services (like a routine physical exam), you may have to pay the full amount.

Your doctor or other health care provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your doctor develop a personalized prevention plan to help you stay healthy and get the most out of your visit. Your visit may include:

• Routine measurements (like height, weight, and blood pressure).
• A review of your medical and family history.
• A review of your current prescriptions.
• Personalized health advice.
• Advance care planning .

Your doctor or other health care provider will also perform a cognitive assessment to look for signs of dementia, including Alzheimer’s disease. Signs of cognitive impairment include trouble remembering, learning new things, concentrating, managing finances, and making decisions about your everyday life. If your doctor or other health care provider thinks you may have cognitive impairment, Medicare covers a separate visit to do a more thorough review of your cognitive function and check for conditions like dementia, depression, anxiety, or delirium and design a care plan.

If you have a current prescription for opioids, your doctor or other health care provider will review your potential risk factors for opioid use disorder, evaluate your severity of pain and current treatment plan, provide information on non-opioid treatment options, and may refer you to a specialist, if appropriate. Your doctor or other health care provider will also review your potential risk factors for substance use disorder, like alcohol and tobacco use , and refer you for treatment, if needed. 

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What Happens During a Wellness Visit?

Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital.

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Importance of a Wellness Visit

• What to Expect
• How to Prepare

A wellness visit is a health check-up that is typically conducted on an annual basis. It involves visiting your healthcare provider to check your vitals, screen for health conditions , and develop a healthcare plan for your needs.

The aim of a wellness visit is to promote health and prevent disease and disability.

This article explains why annual wellness visits are important, what you can expect during the process, and how to prepare for it.

These are some reasons why wellness visits are important.

Prevent Diseases

Most healthcare visits are categorized under diagnostic care; when you have a health problem, you visit a healthcare provider who assesses your symptoms, diagnoses your condition, and prescribes a treatment plan.

A wellness visit on the other hand is a preventative healthcare measure. The aim of preventative healthcare is to help you maintain good health and prevent health problems before they develop. The goal is to help you live a longer, healthier life.

Wellness visits assess your lifestyle, evaluate health risks, and screen for health conditions, in order to prevent health problems or catch them in the early stages. Instead of waiting to see a healthcare provider once you have a health problem, the idea is to be proactive about your health and work with your healthcare provider to prevent health problems.

People tend to think that it’s fine to skip their annual wellness visit if they’re feeling healthy. However, a 2021 study notes that wellness visits can play a role in catching chronic health conditions early, as well as helping people control for risk factors that could cause them to develop health issues down the line.

Reduce Medical Costs

Wellness visits can help prevent disease and disability, which in turn can help reduce medical costs. According to a 2016 study, a focus on preventive healthcare can significantly reduce medical costs and improve the quality of healthcare services.

What to Expect During a Wellness Visit

A wellness visit may be performed by a healthcare provider such as a doctor, nurse practitioner, clinical nurse specialist, physician assistant, or other qualified health professional.

These are some of the steps a wellness visit may involve:

• Family history: Your healthcare provider may ask you detailed questions about your family’s medical history, to determine whether you are at an increased risk for certain health conditions that may be passed on genetically .
• Medical history: You may also be asked questions about your personal medical history. It can include information about any current or previous diseases, allergies, illnesses, surgeries, accidents, medications, vaccinations, and hospitalizations, as well as the results of any medical tests and examinations.
• Measurements: Your healthcare provider may measure your height, weight, heart rate, blood pressure, and other vital signs. Doing this regularly can help you establish a baseline as well as track any changes in your health.
• Cognitive assessment: Your healthcare provider may assess your ability to think, remember, learn, and concentrate, in order to screen for conditions such as Alzhemer’s disease and dementia.
• Mental health assessment: Your healthcare provider may also assess your mental health and state of mind, to help screen for conditions such as depression and other mood disorders.
• Physical assessment: Your healthcare provider may perform a physical examination to check your reflexes. They may also perform a neurological exam, a head and neck exam, an abdominal exam, or a lung exam.
• Functional assessment: Your healthcare provider may assess your hearing, your vision, your ability to perform day-to-day tasks, your risk of falling, and the safety of your home environment.
• Lifestyle factors: Your healthcare provider may ask you questions about your nutrition, fitness, daily habits, work, stress levels, and consumption of substances such as tobacco, nicotine, alcohol, and drugs.
• Health risk assessment: Based on this information, your healthcare provider will evaluate your health, and determine whether you are at an increased risk for any health conditions.
• Health advice: Your healthcare provider may advise you on steps you can take to improve your health, control risk factors, and prevent disease and disability. This may include nutrition counseling, an exercise plan, flu shot and vaccination recommendations, and fall prevention strategies, among other things.
• Screenings: Your healthcare provider may recommend that you get screened for certain health conditions such as depression , cholesterol, blood pressure, diabetes, cancer, heart disease, or liver conditions. This may involve blood work, imaging scans, or other screening tests. 
• Medication review: Your healthcare provider may review your medication and adjust it, if required. This can include prescription medication, over-the-counter medication, vitamins, supplements, and herbal or traditional medication.
• Referrals and resources: If required, your healthcare provider will provide a referral to other healthcare specialists. They can also provide other resources that may be helpful, such as counseling services or support groups , for instance.
• Medical providers: Your healthcare provider will work with you to create or update a list of your current medical providers and equipment suppliers. This list can be helpful in case of an emergency.
• Healthcare plan: Your healthcare provider will work with you to create a healthcare plan that is tailored to your needs. The plan will serve as a checklist that will list any screenings or preventive measures you need to take over the next five to 10 years.

The screenings, assessments, and healthcare plan can vary depending on factors such as your age, gender, lifestyle, and risk factors.

How to Prepare for a Wellness Visit

These are some steps that can help you prepare for a wellness visit:

• Fill out any required questionnaires: Your healthcare provider may ask you to fill out a questionnaire before your visit. The questionnaire may include some of the factors listed above. Make sure you do it before your visit, so that you can make the most of your time with your healthcare provider.
• Carry your medications: If possible, try to carry your medications with you to show them to your healthcare provider.
• Take your medical documents along: It can be helpful to carry your prescriptions, immunization records, as well as the results of any medical tests or screenings you have had, to help give your healthcare provider a more accurate picture of your health status.
• Ask someone to go with you: You may want to take a trusted friend or family member along with you for the wellness visit. They can assist you if required, take notes for you, ask questions, and help you remember your healthcare provider’s instructions.
• Note down questions and concerns: A wellness visit is a good opportunity to ask your healthcare provider any questions you have about your health and tell them about any health problems or concerns you have. Making a list and carrying it with you to the visit can help ensure that you don’t miss anything.
• Check your insurance plan: Most insurance plans cover wellness visits; however, what is covered as part of the wellness visit can vary depending on the plan. It can be helpful to know what preventative services and wellness visits your plan offers. It’s important to check that your healthcare provider takes your insurance and to inform them that you’ll be coming for a wellness visit when you schedule your appointment.

A Word From Verywell

A wellness visit can help you evaluate your health status, understand your risk for specific health conditions, and give you the information and resources you need to improve your health.

After you go for a wellness visit, it’s important that you start implementing your healthcare provider’s advice, take any follow-up appointments necessary, and take steps to improve your health.

U.S. Department of Health and Human Services. Get your wellness visit every year .

University Hospitals. What you need to know about wellness visits .

Liss DT, Uchida T, Wilkes CL, Radakrishnan A, Linder JA. General health checks in adult primary care: a review . JAMA . 2021;325(22):2294-2306. doi:10.1001/jama.2021.6524

Musich S, Wang S, Hawkins K, Klemes A. The impact of personalized preventive care on health care quality, utilization, and expenditures . Popul Health Manag . 2016;19(6):389-397. doi:10.1089/pop.2015.0171

Alzheimer’s Association. Annual wellness visit .

University of Michigan Health. Your yearly wellness visit .

By Sanjana Gupta Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

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How to perform services that increase primary care revenue

CMS states it wants to increase pay to primary care physicians.  And while we might quarrel with their strategies or with the speed of achieving the goal, few would quarrel with the goal itself.  In recent years, CMS has developed HCPCS codes and adopted CPT codes, some limited to primary care and some not specialty restricted but all likely to be reported by primary care practices. Meanwhile, although payment systems are moving to outcome and value measures, the revenue for most primary care practices continues to be fee-for-serviced based, and alternate payment models (APM) are built on top of fee-for-service.

Some of the new services defined by CPT HCPCS codes haven’t pleased primary care physicians, either because of the definition of the services or the payment for them.  Working with and listening to primary care physicians, I think that some of these services can be embraced, and some should be ignored, for the time being.  I’m an advocate of implementing Medicare wellness visits and transitional care management services into primary care and setting aside chronic care management for most practices.  Advance care planning will be relevant in selected practices, but not all.  And many other prevention services just don’t pay enough.

There can be significant variation in work RVUs per encounter (or revenue per encounter) within a group.  When I look at this variance, some of it comes from differences in level of service reporting, but more is from the use of wellness visits and transitional care management.

Thumbs up to wellness visits and problem visits at the same encounter

Some physicians objected to the definition of the Welcome to Medicare and initial annual and subsequent annual wellness visits (AWV) because there was no required physical exam.  These visits don’t prohibit doing an exam.  The Welcome to Medicare and initial wellness visit have high work RVUs and payment.  Medicare allows a physician to bill a problem-oriented visit on the same day, as long as the documentation for the wellness visit isn’t used to select the level of problem-oriented visit.  The wellness visits don’t require HPI, ROS, exam or assessment and plan of a problem.  When I review documentation, I find that many of these visits document the requirements of the wellness visit and the key components of a problem-oriented visit.

In practices that have implemented the wellness visits successfully, staff members collect and record the data for the wellness visit, and the physician or non-physician practitioner (NPP) documents the personalized prevention plan and, if relevant, the problem-oriented visit.  Of course, both must be documented — describe the status of the patient’s chronic diseases in the HPI, do an exam and note the assessment and treatment at the end of the note.  Reporting wellness visits and when relevant, wellness visits and problem-oriented visits on the same day is good for the patient and good for the practice.

Thumbs up to transitional care management (TCM)

Primary care practices are already managing the transition for hospitalized patients to home, and getting paid only for the office visit.  TCM allows the group to be paid for the work the physician, NPP, and staff are already doing.   It requires a phone call to the patient in two business days, a visit in 7 or 14 days (depending on the code), reviewing the discharge summary and medication reconciliation.  It is not for every discharge.  It is for patients who need additional non-face-to-face support by the medical and clinical staff in the transition to home.  It has high work RVUs and reimbursement.  CMS changed the rules January 1, 2016, allowing the visit to be billed on the day of the E/M office visit, rather than waiting 30 days from the date of discharge.  This is a definite yes: get paid for the work the practice is now doing for free.

Thumbs down to chronic care management (CCM)

CMS states it does not have statutory authority to provide a per member per month benefit for managing patients with chronic diseases.  Instead, they can pay monthly for 20 minutes of clinical staff time for patients with two or more significant chronic illnesses.  Staff must count minutes, and only report the service in months they have 20 minutes.  A care plan must be developed at a “comprehensive” E/M service, the patient must sign informed consent, and other physicians who care for the patient must have electronic access to the care plan, not via fax.  There are practices that can do this, but not most.  All for about $40/month.  My advice: Wait on CCM unless you have a very sophisticated case management program in place.

Thumbs up, equivocally, to advance care planning (ACP)

Beginning in 2016, physicians and NPPs can be paid for discussion of end of life issues with patients and/or family members.  The Medicare payment is about $86 for a discussion of 30 minutes.  Since coding is through the looking glass, a clinician must meet over half of 30 minutes, 16 minutes, to bill for the service.  That’s a long time for a service in the office. In can be billed with an office visit, but the time of the office visit and the time of the ACP can’t be double-counted.  When I think it will be useful is for a patient’s family member who wants to come in to discuss a change in the patient’s condition and long-term plans.  Or, for a physician and family member of a hospitalized patient.  After rounding in the morning, a physician could have a discussion with a family member in making end of life decisions.  This isn’t a code that can be used every day of a hospitalization, but when the patient’s condition changes and warrants the discussion.  When it is done on the same day a wellness visit and submitted with modifier 33, there is no co-pay or deductible.  But, it might be difficult to perform on the day of a wellness visit because the wellness visit is time-consuming on its own.

Thumbs down to HCPCS codes with low RVUs

CMS is required to cover any service that the USPSTF gives an A or B rating.  But, that doesn’t mean they have to pay adequately for the service. If you download the CMS preventive medicine chart you’ll see some of these services.  G0442 screening for alcohol misuse, 15 minutes.  Even using the CPT rule of meeting over half of the threshold, does alcohol screening take 8 minutes?  And the payment is under $20. Annual depression screening is reported with code G0444, also a 15-minute code.  The patient filling out the PHQ9 doesn’t take 8 or 15 minutes, and it also has a payment rate of under $20.  15 minutes of behavioral counseling for obesity, G0447, has a slightly higher reimbursement rate. Of course, practices will screen for alcohol misuse and depression, but the HCPCS G-codes will probably not describe the service that was performed.

If your primary care practice hasn’t adopted the wellness visits and TCM, I urge you to take a second look at implementing them. Both AAFP and ACP have resources that will help.

Betsy Nicoletti is president, Medical Practice Consulting and author of Auditing Physician Services. She blogs at  Nicoletti Notes .

Image credit:  Shutterstock.com

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Blog / 2023 Physician Work RVU Increases Finalized by Medicare

The 2023 Medicare Physician Fee Schedule Final Rule was released on November 1, 2022. The final rule includes CPT code changes recommended by the American Medical Association (AMA). The changes are numerous and vary in type, but the result is an overall increase in work Relative Value Units (RVUs) for nearly all physicians who provide evaluation and management (E&M) services in hospitals and nursing facilities .

2023 Inpatient E&M Code Changes

The Medicare Physician Fee Schedule Final Rule (2023 Final Rule) includes both increases and decreases in work RVU values for E&M services provided in hospital and nursing facility settings. Generally, the most used billing codes (99232, 99233, 99308, and 99309) within this subset are all going to realize double digit increases in work RVUs.

Table 1: Proposed 2023 E&M Code Updates

Source: Comparison of 2023 Final Rule to RVU22C

The work RVU changes in the 2023 Final Rule are more complex than those in the 2021 Final Rule. The 2021 Final Rule only increased work RVUs for seven outpatient services codes. Forecasting the 2023 Final Rule accurately requires  crosswalking  many deleted codes with substitute codes. The AMA and Medicare have deleted hospital  observation  E&M procedure codes and merged those services into the codes for hospital  inpatient  E&M services. Visit codes for E&M services in assisted living and custodial care facilities are also being consolidated into the general home visit service codes.

Table 2: 2023 Deleted Codes & Substitutes

Source: AMA CPT Evaluation and Management Code and Guideline Changes

2023 Overall Medicare Work RVU Impact by Specialty

LBMC calculated the overall work RVU impact of the 2023 Final Rule changes by specialty by applying the new work RVU values to the billing data contained in the public  2019 Medicare Provider Utilization and Payment  data set.

This analysis indicates that hospitalists, infectious disease physicians, geriatricians, PM&R, hematologists, psychiatrists, internists, palliative care, and other specialists who practice in hospital and nursing facilities will realize the most increases in work RVUs from the 2023 Final Rule changes. Advanced Practice Providers (APPs) specializing in geriatrics, acute medicine, mental health, and other facility-based specialties are similarly affected.

When combined with the 2021 outpatient E&M changes, dozens of specialties will realize double-digit increases in work RVUs.

Table 3: Estimated Overall Changes in Work RVUs by Specialty

Note: Overall wRVU % change by specialty does not reflect the skewed impact within specialties. Disclaimer: No estimate is made for changes in existing coding patterns other than substitutes.

Highly Variable Work RVU Impacts within Specialties

The  overall  work RVU increases projected in the previous section do not reflect the expected variation in work RVU changes among physicians within each specialty. The 2023 Final Rule includes both increases and decreases in work RVUs among the CPT codes affected. The severity and complexity of patient illnesses varies from physician-to-physician within each specialty. The proportion of E&M services provided in hospitals, offices, and nursing facilities can also vary substantially within specialties like hospital medicine,  psychiatry , and  geriatrics .

For example, the table below summarizes the separate and combined changes for the 2021 Final Rule and 2023 Final Rule. The percentage changes from 2020 to 2021 in the left-most column illustrate the distribution of work RVU increases exclusively for  outpatient  E&M services. The percentage changes from 2022 to 2023 in the center column illustrate the distribution of work RVU increases exclusively for  inpatient  E&M services. The percentage changes in the right-most column illustrate the combined effects of both the 2021 and 2023 rules. Predictably, the sample of 13,529 hospitalists analyzed in the following table were not impacted by the 2021  outpatient  E&M work RVU changes at all. The variation of  inpatient  E&M service severity and coding among these hospitalists yields a wide range of estimated effects from 2% decreases in work RVUs at the 10 th  percentile to 15% increases in work RVUs at the 90 th  percentile.

Table 4: Estimated Work RVU Change Variability within Hospital Medicine (n=13,529)

Disclaimer: No estimate is made for changes in existing coding patterns other than substitutes

Forecasts estimate about half of physicians practicing Geriatric Medicine will realize increases in work RVUs during 2023 as a result of E&M updates for both inpatient and nursing facility services. When combined with the prior outpatient E&M changes from 2021, nearly all geriatricians are forecast to experience work RVU increases from 2020 to 2023.

Table 5: Estimated Work RVU Change Variability within Geriatric Medicine (n=3,013)

Adapting to changes in work rvu production, compensation & reimbursement.

On a combined basis, the 2023 Final Rule and the 2021 Final Rule materially change the Resource-Based Relative Value System on which physician reimbursement, productivity, and compensation is built. Commercial insurance carriers will not emulate Medicare’s changes in their own reimbursement systems overnight. Accordingly, an added level of thoughtfulness is required when using industry compensation and production surveys to set physician compensation. Employers of specialists that were unaffected by the 2021 Final Rule may find that they are materially affected by the 2023 Final Rule.

The path forward begins with identifying the financial impact of the 2021 and 2023 work RVU changes on production, compensation, and reimbursement for your healthcare professionals. Once the financial impact is known, the various options of partially or fully adopting the new production system changes can be assessed within your budgetary resources and restrictions.

LBMC Advisory Services has a  team of experts  exclusively dedicated to physician compensation analysis, planning, strategy and valuation. Contact LBMC today for assistance with productivity and compensation forecasts, scenario analyses, compensation planning, and questions regarding the impact of the 2023 Final Rule on Fair Market Value compensation analysis.

LBMC’s  Nick Newsad  recently discussed how the 2023 Medicare Physician Fee Schedule Rule will affect physician productivity measurement, compensation, and reimbursement during a webinar on August 4, 2022. Watch the webinar On-Demand:  https://www.lbmc.com/blog/webinar-new-physician-work-rvu-increases/

Nicholas A. Newsad, MHSA works in the Advisory Services Group at LBMC. He can be contacted at [email protected] or 615-309-2489.

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Medicare's wellness coverage offers critical services

Physicians must understand the requirements for billing for Medicare-covered preventive services, such as the “Welcome to Medicare” exam and Annual Wellness Visit (AWV).

I n 2023, as always, ACP remains committed to elevating the role of both treatment and prevention. Providing equitable access to preventive services is an essential part of taking positive, proactive steps toward improving the nation's health. Medicare covers many preventive services to keep patients healthy, and it is critical that physicians discuss with patients which services are right for them and how often they need them.

While the importance of preventive services may be straightforward, billing for Medicare-covered preventive services, such as the “Welcome to Medicare” exam and Annual Wellness Visit (AWV), has its difficulties. Both the “Welcome to Medicare” exam and the AWV capitalize on a discussion about patients' health history, their risk factors for chronic diseases, and their current lifestyle, but the proper order and appropriate circumstances differ substantially. To best avoid denials when submitting claims, physicians must understand the requirements.

“Welcome to Medicare” visits

During the first 12 months a patient is enrolled in Medicare Part B (medical insurance), they are eligible for the “Welcome to Medicare” visit. This is a one-time visit that includes vital measurements, a vision screening, depression screening, and other assessments meant to gauge health and safety. Otherwise known as an Initial Preventive Physical Examination (IPPE) visit, its goals are health promotion and disease prevention and detection.

The “Welcome to Medicare” visit must be coded using G0402. Since this visit is restricted to those who have been enrolled for less than 12 months, once a patient has hit the 12-month mark, G0402 will be denied regardless of whether the IPPE visit previously took place.

Annual Wellness Visits

After a patient has been enrolled in Medicare for 12 months, they become eligible for an AWV. The AWV is a yearly visit to develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA). This service helps provide a clearer picture of the patient's health status from one year to the next, establishes a baseline, and provides longitudinal data to support the physician in managing changes. Medicare will cover an AWV providing a PPP for patients who:

• are no longer within the 12-month period following the patient's Medicare eligibility date for Medicare Part B and
• have not received an IPPE or AWV within the past 12 months.

Patients who completed an IPPE are eligible for the initial AWV on the first day of the same calendar month the following year. The initial AWV must be coded using G0438, with G0439 used to code all subsequent AWVs that occur after the initial AWV. If used correctly, then, G0439 would not be used until G0402 was used to code the IPPE and G0438 was used to code the initial AWV. If the patient never completed an IPPE, G0439 would still be used for any subsequent visits after G0438.

It is very important to note that while the AWV is similar to the IPPE, it includes slightly different required and accepted screenings, as well as separate codes. Since it is assumed that the different types of visits take varying amounts of practice resources, Medicare reimburses these services at different rates. For example, the initial AWV (G0438, RVU=2.60) is reimbursed at a rate that is over 35% higher than the subsequent AWV (G0439, RVU=1.92). This is because the initial AWV is used to collect the library of information that will continually be updated with each subsequent AWV. The result: If your practice regularly misses using the G0438 code for an initial AWV and uses G0439 instead, it could result in a significant loss of revenue.

Evaluation and Management (E/M) services

If the last three years of COVID-19 have taught us anything, it is that things rarely ever go as planned. In some instances, a patient is seen for a wellness visit and has acute symptoms or chronic problems, requiring additional evaluation. These encounters result in confusion about whether it is permissible to bill for the wellness visit and the acute or chronic care in the same visit. Often, usually to avoid audits, physicians are advised not to bill for both services; other times, they are told they can bill for both, but only one will be paid.

Though this guidance may be intended to guard against fraud, waste, or abuse, inappropriately downcoding results in significant amounts of uncompensated care. Physicians are not prohibited from coding and billing for both preventive and problem-focused E/M services when they are performed during the same appointment. Under these circumstances, it is imperative that physicians accurately and completely document all medically appropriate and necessary care and bill for what is documented. It is also important that the elements of the AWV not be replicated in the medically necessary service. In reporting this visit, the physician must append modifier 25 (significant, separately identifiable service) to the medically necessary E/M service to be paid for both. Of note, commercial payers may or may not cover the additional problem-focused E/M service, so physicians should be sure to check with their patients at the time of service to help avoid confusion and frustration related to unexpected charges.

ACP encourages physicians to visit its practice resources website to take advantage of its myriad resources designed to support practices in the provision of preventive services. Many patients think they do not need to see a physician unless they are sick; however, an annual visit is the best prescription for long-term health and wellness. To support your practice, ACP also offers a broad catalog of Medicare coding- and billing-related resources, including a new Coding for Clinicians subscription series, which features a learning module to properly report adult preventive medicine visits, the “Welcome to Medicare” visit, Medicare AWVs, and advance care planning codes. For additional information from CMS, please visit its Medicare Wellness Visits page .

Dejaih Johnson, JD, MPA, is an Associate in ACP's Regulatory Affairs Office.

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Annual Wellness Visits; RVU Reductions; Physician Scribes

Medical coding guidance on Medicare Annual Wellness Visits; RVU reductions; physician scribes; student documentation; and more.

Annual Wellness Visits

Q: I've just been informed by AARP/Secure Horizons/PacifiCare (a Medicare replacement plan) that for a routine physical, I can no longer bill with CPT code 99396-99397. Instead, I am to bill according to Medicare guidelines. Does anyone know the code(s) that I can use to bill for yearly routine physical exam? Does this code(s) apply to all of the Medicare replacement plans?

A: Although I can't say for certain, the Medicare replacement plan is likely directing you to use the new Annual Wellness Visit codes G0438 and G0439. The use of these codes is pretty clearly outlined in the Medicare transmittal R2159CP. What I don't know is what a given Medicare replacement or advantage plan is doing with these directions. They can depart from standard coverage but most that I know of generally follow the guidelines. I would ask the plan if it recognizes the codes above, and ask them to show you the written policy or coverage determination.

RVU Reductions

Q: I have a question regarding work RVUs and multiple procedure reduction with modifier 51. What happens to my work RVUs when I have performed a Mohs excision followed by a closure? Is my work RVU automatically reduced?

A: The paragraph in CPT directly preceding the Mohs codes indicates that repairs, flaps, and grafts should be coded separately. The repair codes are also not listed in CCI as component elements of the Mohs codes, so those codes should not be included. However, as the repair will constitute a multiple procedure, and as it is in the exact same incision/excision site as the first procedure, it will be subject to the multiple procedure guidelines and therefore, it will be reduced by 50 percent. So yes, report modifier 51 on the repair (unless the repair RVU exceeded the excision RVU), and yes, you will see an RVU reduction.

Physician Scribes

Q: I hear of a lot of providers moving toward the use of scribes and I want to know what the rules are regarding nonphysicians acting as scribes for physicians. What exactly does a scribe need to write in the note and what does the physician need to write?

A: If a nurse or nonphysician provider (PA, NP, or CNS) acts as a scribe for a physician, the scribe writing the note (or history or discharge summary, or any entry in the record) should note, "written by xxx, acting as scribe for Dr. Y." Dr. Y should co-sign the note, indicating that it accurately reflects work and decisions made by him.

The scribe should function as a "living recorder," recording the actions and words of the physician in real time. Any other way this is done may be deemed inappropriate and result in a denial if reviewed.

It is inappropriate for an employee of a physician to make rounds and make entries in the record, and then for the physician to make rounds at a later time and note, "agree with above," unless the employee is a licensed, certified provider (PA, NP, or CNS) billing Medicare for services under her own name and number. There is no incident-to billing in the hospital setting (inpatient or outpatient). Thus, the scribe should be merely that, a person who writes what the physician dictates and does. This individual should not act independently, and there is no payment for this activity.

Student Documentation

Q: I'm looking for an opinion regarding how we have our medical students document in patient charts. We know that students can document PMH, FH, SH, and ROS for billing, but not HPI or PE. So we do a kind of "work-around." We have our students document the encounter, then sign as scribe. We then correct and abridge the note to whatever extent necessary. At the bottom of the note, I write something like, "Student Smith acted as scribe for this encounter. I personally performed the history and examination, annotated the above documentation to reflect my findings and assessment, and the plan is based on my assessment and is accurate and complete."

A: This does not strike me as a safe practice at all. The above excerpt says the student is a scribe, however, it references the work the student did. It's a "work-around" as you say, but it works around the rules.

The rules were recently updated in the Medicare teaching guidelines. They state: "Any contribution and participation of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements (other than the review of systems [ROS] and/or past, family, and/or social history [PFSH], which are taken as part of an E&M service and are not separately billable). You, the student, may document services in the medical record; however, the teaching physician may only refer to your documentation of an E&M service that is related to the ROS and/or PFSH. The teaching physician may not refer to your documentation of physical examination findings or medical decision making in his or her personal note. If you document E&M services, the teaching physician must verify and re-document the history of present illness and perform and re-document the physical examination and medical decision making activities of the service."

Note the repeated use of the term "re-document." I think this speaks against your work-around.

Delayed Record Completions

Q: Some of my physicians don't "lock" or "close" their EHR notes until a month, or more, has passed. And, a couple of my physicians still dictate their notes, but can be up to three months late with their dictations. Is there a rule about this?

A: There is no one all-encompassing rule that states when a record needs to be completed. But there are several good reasons why delay is inadvisable. The providers will not remember as many details after time has passed, and so the record will not be as complete as it should be. You shouldn't file claims without the supporting documentation in place. If that isn't incentive enough, CMS says "Medicare expects the documentation to be generated at the time of service or shortly thereafter. Delayed entries within a reasonable time frame (24-48 hrs.) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service."

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at [email protected] or [email protected] .

This article originally appeared in the May 2012 issue of Physicians Practice.

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In family medicine practices today, coding drives revenue. Even for employed physicians, coding drives compensation because it is a proxy for productivity. Although many practices are wisely preparing for value-based payment, physicians still need to optimize current revenue and compensation through correct coding. After all, 95 percent of all visits are still paid using fee for service. 1

Unfortunately, many groups don't bother monitoring their coding patterns or optimizing their coding. They seem to believe that variation in levels of evaluation and management (E/M) service among physicians is unavoidable and beyond their control. It is not. Using a relatively simple but vital tool – a “CPT frequency report” – practices can identify coding patterns that result in lost revenue. (See “ What is a CPT frequency report? ”)

Differences in specialty and scope of practice result in some appropriate variation in E/M coding patterns. However, I recently reviewed the CPT frequency report of a multisite primary care group and found variation that had resulted in significant differences in their work relative value units (RVUs) per encounter and total revenue.

This article draws on that analysis to identify four often overlooked coding and revenue opportunities.

WHAT IS A CPT FREQUENCY REPORT?

A CPT frequency report, like the sample shown here, is simply a listing of all CPT codes billed by each physician for a given period, typically a year. The report lists the code, the code description, and the number of times it was billed. Physician leaders and managers can compile the report annually from the practice's billing system and get a snapshot of the group's coding patterns, without having to review individual charts and documentation. Although there will always be variation due to differences in practice patterns and patient populations, this tool can help reveal avoidable coding variances due to overcoding, undercoding, missed charges, or compliance issues.

For example, the report shows that Physician A reports code 99213 almost three times as often as code 99214, although the benchmark ratio is 1.08:1. There are no Medicare wellness visits or transitional care management services reported. There are no smoking cessation services or certification of home health services reported either. Nebulizer treatments are reported 16 times, but the medication for the nebulizer isn't billed. Influenza vaccinations are reported but no administration. New patient visits are billed at much higher levels than benchmarks.

Physician B has a ratio of 99213s to 99214s that is in line with the benchmark. This physician reports Medicare wellness visits and transitional care management services (both levels), as well as a few smoking cessation services. There are no home health certification services reported, however.

Benchmarks are derived from the Centers for Medicare & Medicaid Services, E/M Codes by Specialty. Available at: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicarefeeforsvcpartsab/medicareutilizationforpartb

1. Bill for high-value services you've probably been providing for free

Three high-value services family physicians are likely providing but not always billing for are transitional care management, chronic care management, and advance care planning.

Transitional care management . This service involves seeing patients who are discharged from the hospital or another facility. It includes talking to the patient by phone, seeing the patient for an office visit after discharge, reconciling medications, reviewing the discharge summary, coordinating care, and providing patient and family support.

In the CPT frequency analysis referenced earlier, only 9 out of 26 physicians billed any transitional care management services during the year. One physician actually reported a number of discharge visits but not a single transitional care management service. Without reviewing individual records, it's impossible to know how many of the group's patients were eligible for transitional care management, but it is safe to assume that all physicians had provided the service at some point over the year. In many cases, they likely billed these services as an office visit (e.g., CPT code 99214) instead of a transitional care management service (e.g., CPT code 99495). The difference between the two codes is 0.6 work RVUs or approximately $57.32. (See “ RVU and payment comparisons .”)

RVU AND PAYMENT COMPARISONS

The table below demonstrates the RVUs and payment allowances for services commonly provided by family physicians. Payment amounts shown here are not geographically adjusted.

Every CPT code is assigned relative value units (RVUs) that help determine payment and reflect the following:

The level of physician work (the physician's time, skill, training, and intensity required),

Practice expenses (rent, staffing, equipment, and supplies for either “non-facility” settings such as free-standing physician offices or “facility” settings such as inpatient settings or hospital outpatient clinics),

Professional liability (the physician's malpractice expense).

Total RVUs are then multiplied by a conversion factor set by Congress (currently $35.804) to determine the national payment rate. A geographic adjustment is applied to determine local payment rates. To look up local rates, use the Physician Fee Schedule Search .

One physician in the analysis managed to report transitional care management services but recorded all of them at the highest level. This is not likely accurate and could pose a compliance problem. The Centers for Medicare & Medicaid Services (CMS) has stated in the past that a more expected ratio for transitional care management services is three moderate complexity visits for every one high complexity visit.

The requirements for code 99495 are as follows:

Communication (direct contact, telephone, or electronic) with the patient or caregiver within two business days of discharge,

Medical decision making of at least moderate complexity during the service period,

A face-to-face visit within 14 days of discharge.

The requirements for code 99496 are as follows:

Medical decision making of high complexity during the service period,

A face-to-face visit within seven days of discharge.

Much of the work of transitional care management is done by clinical staff supervised by the physician. A staff member calls the patient within two business days of discharge, opens the template on the day of the face-to-face visit, and provides coordination or educational services as directed by the physician. By capturing these codes, the physician is awarded additional work RVUs for the direction and oversight, and the practice is paid for work it previously did for free or for a lesser rate. Note that CMS now allows the physician to bill the transitional care management code on the day of the face-to-face visit, rather than waiting until 30 days after the discharge. This change should make billing for this service even easier.

Chronic care management . At the time of the group's CPT frequency analysis, chronic care management codes (and advance care planning codes) had not yet been released, so they did not factor into the analysis. Nevertheless, they represent clear coding and payment opportunities for family physicians.

Chronic care management applies to patients who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the patient's death, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. There is a single code – 99490. The three key requirements for billing chronic care management are 1) having a scanned, signed patient agreement, 2) having a patient-centered care plan, and 3) having a monthly log showing at least 20 minutes of staff contact time. Staff are key to managing these tasks. (For downloadable tools to help you meet these requirements, see “ Chronic Care Management and Other New CPT Codes ,” FPM , January/February 2015.)

Advance care planning . This service is now reportable with two new codes:

99497, “Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate,”

+99498, “each additional 30 minutes (list separately in addition to code for primary procedure).”

Providers can use these codes to report the face-to-face service even if the visit does not involve completing the relevant legal forms. The service can occur as a stand-alone visit or as part of an E/M visit. In the latter case, time spent on E/M services would not count toward time used for advance care planning. (For more on the advance care planning codes, see “ Coding and Billing Rules in 2016: Out With the Old, In With the New ,” FPM , January/February 2016.)

2. Perform wellness visits and, when appropriate, perform them with a problem-oriented visit on the same day

Many physicians I work with objected to the “Welcome to Medicare” visit (G0402-G0405) and annual wellness visits (G0438-G0439) when they were introduced many years ago, noting that these visits didn't require a physical exam. Physicians weren't prohibited from doing an exam, of course; the real issue was that they didn't see the value in the screening and health-risk-assessment tools required for the visit. Instead of incorporating the visits, many physicians continued to schedule only problem-oriented visits for Medicare patients and, at the end of one of those visits, would provide – free of charge – referrals for screenings and advice about immunizations. This resulted in lost revenue.

Practices that have successfully integrated wellness visits into their physicians' days rely on ancillary staff to collect the data needed for these visits. The patient can often fill out the required screening tool, or a staff member can collect the data. The family physician can then provide the personalized advice.

In the CPT frequency analysis referenced in this article, 10 of the 26 clinicians didn't report any wellness visits. Of the clinicians who did report wellness visits, the volume varied from 62 visits to 452 visits in a year. In place of wellness visits, they coded established patient visits, usually a 99214. The difference in work RVUs between a level-four established patient visit (99214) and an initial annual wellness visit (G0438) is 0.93; the revenue difference, based on national amounts, is $64.49.

Most Medicare patients have chronic problems to discuss at their wellness visits. CMS allows physicians to report both the problem-oriented visit and the wellness visit on the same day, and the revenue implications of reporting both services are significant. (See “ The bottom line of billing a problem-oriented and wellness visit .”) Of course, the problem-oriented visit must be medically necessary, and both the wellness visit and the problem-oriented visit must be documented.

THE BOTTOM LINE OF BILLING A PROBLEM-ORIENTED AND WELLNESS VISIT

The following tables show the revenue potential of reporting a problem-oriented visit (such as a 99213 or 99214) along with a wellness visit (such as an initial or subsequent annual wellness visit) when both services are provided on the same day.

One of the billing requirements is that none of the documentation for the wellness visit can be used to select the level of service for the problem-oriented visit. To separate the documentation, physicians can either create two separate notes, which requires more work, or create one note for both services but clearly delineate the problem-oriented history, exam, and decision making from those of the preventive service. Because a wellness visit does not include the HPI, ROS, exam, or assessment/plan related to acute or chronic conditions, when those components are documented, it is a good indication that you should bill for both a problem-oriented visit and a wellness visit.

One group I know of has taken the opposite approach. It adds wellness visits to scheduled office visits. The coding and revenue are the same as adding a problem-oriented visit to a scheduled wellness visit, but the framework changes. The nurse and physician look at the day's schedule and identify Medicare patients scheduled for office visits for whom a wellness visit could be added. Of course, additional time may be needed for the risk assessment and counseling, but nurse practitioners or other staff can help with the wellness portion of the visit. The staff document the additional screenings related to the wellness visit, and the physician or other provider documents the problem-oriented visit and the personalized advice given based on the screening information documented by the staff. Since the wellness visit is covered entirely by Medicare, without a copay or deductible, the practice has had very few patient complaints with this method.

The work of the wellness visit is two-fold: 1) screening for depression, ability to perform activities of daily living, health risk assessment, and safety at home and 2) giving personalized advice based on the responses. All of the screening and data collection is staff work. Giving personalized advice is physician work, and most physicians are already doing this. Embracing and reporting these services supports physicians in achieving RVU and revenue goals without adding additional patient visits.

3. Identify missed ancillary charges and have a system for capturing them

By simply reviewing the CPT frequency report, even without looking at a single chart, the group was able to identify lost ancillary charges.

One of the more concerning issues was that only two of the 26 physicians in the group reported home health certifications (G0180) and recertifications (G0179) even though the process is simple. Keeping track of certifications and recertifications is another staff job. The physician develops the plan, answers the phone calls, writes the orders, and signs the certification. Staff can implement a billing process without additional burden to the physician. One key is for staff to copy the necessary forms for the biller, since they typically arrive by fax and are sent back that way. Implementing a system for this allows the physician to be paid for work already being done. A single home health certification is worth about $54.

Additionally, only four clinicians in the group billed for smoking cessation (G0436-G0437 or 99406-99407). Although the work RVUs and payment are small (about $14 for 3 minutes to 10 minutes of counseling), this represents work being given away for free. Any time spent on smoking cessation counseling should be documented and billed. If this service is billed with an E/M service on the same day, simply attaching modifier 25 to the E/M code will communicate that it is significant and separately identifiable from the tobacco cessation counseling.

The following discoveries also raised questions about missed charges or incorrectly posted charges:

Vaccines and medications were given without an administration code, which is always a billable service,

Nebulizer treatments were given, but medications weren't charged,

Finger-stick services were billed (although this is a bundled charge), but no lab test was reported,

Only half of the clinicians reported a single electrocardiogram in a year,

Amounts billed for CLIA-waived tests varied widely, from $221 to $5,341 per physician.

4. Pay attention to your 99213s and 99214s

Many physicians are tired of discussing the difference between a 99213 and a 99214. They have received conflicting messages from one coder to another, from electronic health record vendors, and from managers. But the frequency report for the primary care group showed that the variation between the 26 physicians, advanced practice nurses, and physician assistants was too large to ignore. For example, two physicians reported all new patient visits as level-four services, while other physicians rarely used the code.

Practices should review two key metrics. The first metric is the percentage of 99214 visits as a percentage of all established patient visits (99211-99215). The CMS benchmark is 43.3 percent for physicians. 2 The other metric to track is the ratio between 99213 and 99214 visits. The CMS norm is 1.08. 2 In other words, you should expect the ratio of 99213 visits to 99214 visits to be almost equal. If a physician is billing three, four, or five times as many 99213s as 99214s, or vice versa, do a chart review to determine whether the coding is accurate (not likely) or the physician needs some coding education.

For a quick refresher, according to Medicare's Documentation Guidelines for E/M Services, a 99213 code requires two out of three of the following:

Expanded problem-focused history (chief complaint, 1 to 3 elements of the HPI, and pertinent ROS),

Expanded problem-focused exam (6 to 11 elements),

Low-complexity medical decision making.

A 99214 code requires two out of three of the following:

Detailed history (chief complaint, 4 or more elements of the HPI or status of 3 or more chronic diseases, 2 to 9 elements of the ROS, and 1 element of the PFSH),

Detailed exam (12 or more elements),

Moderate-complexity medical decision making.

(For more on this topic, see “ Coding ‘Routine’ Office Visits: 99213 or 99214? ” FPM , September 2005.)

“No dollar left behind”

The medical director of an accountable care organization uses this phrase to remind family physicians that coding matters, even as the system is driving toward value-based payment. Physicians are naturally more interested in patient care and outcomes than CPT codes, but coding currently drives the lion's share of revenue in most family medicine practices. Coding produces revenue for the practice and, for employed physicians, determines RVU-based compensation. Until practices are paid solely for value and outcomes, coding will continue to matter greatly.

Zuvekas SH, Cohen JW. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Aff. 2016;35(3):411-414.

Benchmarks derived from Centers for Medicare & Medicaid Services, E&M Codes by Specialty, 2012. Available at: go.cms.gov/1Twbus7 .

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