evaluation visit meaning

Evaluation Site Visits – Seeing is Knowing

• Posted on April 3, 2019
• In Data Collection , Evaluation

Gathering evaluative information about a program or initiative often relies upon evaluators physically visiting the program’s location in order to observe program operations, to collect evidence of the program’s implementation and outcomes, and to interview staff and program participants. The empirical and observational nature of site visits offer evaluators a unique lens through which to “see” what the program actually is, and how it attempts to achieve the desired outcomes it hopes to achieve.

In their influential article, “Evaluative Site Visits: A Methodological Review,” American Journal of Evaluation, Vol. 24, No. 3, 2003, pp. 341–352, Lawrence, Keiser, and Levoie note that, “An evaluative site visit occurs when persons with specific expertise and preparation go to a site for a limited period of time and gather information about an evaluation object either through their own experience or through the reported experiences of others in order to prepare testimony addressing the purpose of the site visit.” Unlike case studies, which are of longer duration and often of greater depth, and which seek to describe in detail the instance or phenomena under study, site visits are of limited time duration, and are focused on gathering data that ultimately will inform judgement about a program’s worth/value. Site visits typically involve the use of a number of qualitative methods (e.g., individual and focus group interviews, observations, document review, etc. For more information on the kinds of data that site visits permit, see our previous blog post “Just the Facts: Data Collection.”

Michael Quinn Patton summarizes the essential elements of an evaluation site visit:

• Competence–  Ensure that site‐visit team members have skills and experience in qualitative observation and interviewing. Availability and subject matter expertise does not suffice.
• Knowledge–  For an evaluative site visit, ensure at least one team member, preferably the team leader, has evaluation knowledge and credentials.
• Preparation–  Site visitors should know something about the site being visited based on background materials, briefings, and/or prior experience.
• Site participation– People at sites should be engaged in planning and preparation for the site visit to minimize disruption to program activities and services.
• Do no harm– Site‐visit stakes can be high, with risks for people and programs. Good intentions, naiveté, and general cluelessness are not excuses. Be alert to what can go wrong and commit as a team to do no harm.
• Credible fieldwork– People at the site should be involved and informed, but they should not control the information collection in ways that undermine, significantly limit, or corrupt the inquiry. The evaluators should determine the activities observed and people interviewed, and arrange confidential interviews to enhance data quality.
• Neutrality– An evaluator conducting fieldwork should not have a preformed position on the intervention or the intervention model.
• Debriefing and feedback– Before departing from the field, key people at the site should be debriefed on highlights of findings and a timeline of when (or if) they will receive an oral or written report of findings.
• Site review– Those at the site should have an opportunity to respond in a timely way to site visitors’ reports, to correct errors and provide an alternative perspective on findings and judgments. Triangulation and a balance of perspectives should be the rule.
• Follow-up– The agency commissioning the site visit should do some minimal follow‐up to assess the quality of the site visit from the perspective of the locals on site.

Lawrence, Keiser, and Levoie argue that evaluative site visits are not merely a venue in which a range of predominately qualitative methodologies are used, but a specific kind of methodology , which is distinguished by its use of observation. “We believe site visit methodology is based on ontological beliefs about the nature of reality and epistemological beliefs about whether and how valid knowledge can be achieved. Ontologically, in order to conduct site visits the evaluator must assume that there is a reality that can be seen or sensed and described. Epistemologically, site visits are based in the belief that site visitors are legitimate, sensing instruments and that they can obtain valid information through first-hand encounters with the object being evaluated.”

Accordingly, site visits are where evaluators can get “the feel” of what a program is and does. As a result, site visits are a critical means through which evaluators gather and interpret data with which to make judgements about the value and effects of a program.

“Evaluative Site Visits: A Methodological Review,” Frances Lawrenz, Nanette Keiser, and Bethann Lavoie, American Journal of Evaluation, Vol. 24, No. 3, 2003, pp. 341–352.

See Michael Quinn Patton quoted in Editors’ Note , Randi K. Nelson and Denise L. Roselan, New Directions in Evaluation , December, 2017

“Using Qualitative Interviews in Program Evaluations”

Conducting and Using Evaluative Site Visits: New Directions for Evaluation, Number 156, February 2018

“Developmental Evaluation: Evaluating Programs in the Real World’s Complex and Unpredictable Environment”

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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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At first a preventive visit and office visit may seem similar, but there is a difference. Knowing which to schedule can help ease any confusion.

You schedule preventive visits which are annual physicals, well child exams and wellness exams to help prevent or detect any health concerns. This is also known as your annual wellness exam or annual health maintenance exam. Confusion comes when at your annual checkup you want to discuss or receive treatment for a new or existing condition that requires action. This is where a preventive visit can become an office visit and your bill can be impacted.

You schedule an office visit, or problem-related service, for problem focused care, meaning you notice symptoms and want to talk with your provider. In your preventive visit if a problem is addressed and needs to be treated, your provider’s office is required to bill as a separate office visit, due to action for treatment needed.

What is a preventive visit?

• Complete physical exam (annual health maintenance exam)
• Blood pressure, blood glucose and cholesterol screening tests
• Pelvic exams, pap smear
• Prostate and colorectal cancer screenings
• Sexually transmitted infection testing
• Thorough review of medical history, general health and well-being
• Vaccination review and update
• Developmental screenings
• Evaluation of future risks

What is an office visit?

• Diagnosing and monitoring specific medical conditions
• Addressing medical concerns and treatment plans
• Post hospitalization discharge care
• Medication refills
• Specialist referrals
• Testing/lab results
• Addressing new or worsening symptoms
• Depending on benefits an office visit can result in additional costs

Before scheduling an appointment state clearly whether this will be a wellness exam or if this appointment will be to discuss and treat new health concerns or symptoms. If a wellness exam is spent on specific or new health issues and treated it will no longer be considered a preventive visit, and it will be billed as an office visit.

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An Evaluator’s Guide to Performing Successful Site Visit Observations

For external evaluators, site visits (e.g. visiting schools) provide an opportunity to experience the activity, program, or product first-hand while also offering a chance to connect in-person with participants from a study. As these observations provide an important addition to report findings, Magnolia Consulting follows several steps for successfully navigating site visit observations. Based on our experience, here are five key guidelines for successful site visit observations:

• Conduct an in-person study orientation. Conducting an in-person study orientation before site visits offers the opportunity to meet and interact with participants, which helps to establish a trusting relationship. Having a positive rapport with participants is important as it allows for open communication and can help reduce any participant concerns associated with site visit observations. During the study orientation, inform participants of details about the purpose of the site visits, expectations for participation, and how site visits will be scheduled to minimize disruption in the classroom. During the orientation, explain how the data will be used and how evaluators will maintain participant confidentiality. If the budget does not allow for an in-person orientation, webinars with video access are also a helpful tool to introduce yourself to the participants.
• Create an observation protocol.  Using an observation checklist or protocol helps to reduce bias associated with observations and assures that preestablished guidelines are followed. These protocols typically focus on the quality and extent to which an activity, program, or product is implemented and/or aligned to best instructional practices in the field (i.e., reading instruction, STEM). If multiple evaluators perform observations across participants or sites, the measure should be checked across observers for agreement and accuracy.
• Enlist a site coordinator . If budget allows, plan for having an on-site coordinator who knows the site’s participants and inner workings. This individual can communicate with the evaluation team’s program coordinator on details throughout the study such as scheduling observations across multiple participants at the site. Furthermore, the site coordinator can communicate details with participants before the observation and answer any questions that arise. In addition to coordinating site visit observations, the site coordinator might be responsible for other helpful tasks such as managing consent forms and ensuring assessments are distributed and returned in an organized manner.
• Be flexible with scheduling.  Allowing flexibility and accommodating a site’s scheduling needs supports understanding and recognition of “real world” complications. If possible, create a schedule that follows the site’s established routines. This may require conducting observations across several days rather than consolidating multiple sessions into a shorter timeframe. If the evaluation budget is limited and requires observations to be performed within a brief period, work with the site coordinator to determine another mindful, yet suitable schedule. If appropriate, send participants a direct email one week prior to the visit restating the purpose of the observation and confirming the schedule. This can help avoid an observation from being unannounced.

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What is evaluation?

There are many different ways that people use the term 'evaluation'. 

At BetterEvaluation, when we talk about evaluation, we mean:

any systematic process to judge merit, worth or significance by combining evidence and values

That means we consider a broad range of activities to be evaluations, including some you might not have thought of as 'evaluations' before. We might even consider you to be an evaluator, even if you have never thought of yourself as an evaluator before!

Different labels for evaluation

When we talk about evaluation, we also include evaluation known by different labels:

• Impact analysis
• Social impact analysis
• Appreciative inquiry
• Cost-benefit assessment

Different types of evaluation

When we talk about evaluation we include many different types of evaluation - before, during and after implementation, such as:

• Needs analysis —​ ​which analyses and prioritises needs to inform planning for an intervention​
• Ex-ante impact evaluation — which predicts the likely impacts of an intervention to inform resource allocation
• Process evaluation —​ which examines the nature and quality of implementation of an intervention​
• Outcome and impact evaluation —​ which examines the results of an intervention​
• Sustained and emerging impacts evaluations —​ which examine the enduring impacts of an intervention sometime after it has ended​
• Value-for-money evaluations —​ which examine the relationship between the cost of an intervention and the value of its positive and negative impacts​
• Syntheses of multiple evaluations —​ which combine evidence from multiple evaluations​

Monitoring and evaluation

When we talk about evaluation we include discrete evaluations and ongoing monitoring, including:

• Performance indicators and metrics
• Integrated monitoring and evaluation systems

Evaluations by different groups

When we talk about evaluation we include evaluations done by different groups, such as:

• External evaluators
• Internal staff
• Communities
• A hybrid team

Evaluation for different purposes

When we talk about evaluation we include evaluations that are intended to be used for different purposes:

• Formatively, to make improvements
• Summatively, to inform decisions about whether to start, continue, expand or stop an intervention.

Formative evaluation is not the same as process evaluation. Formative evaluation refers to the intended use of an evaluation (to make improvements); process evaluation refers to the focus of an evaluation (how it is being implemented).

As you can see, our definition of evaluation is broad. The resources on BetterEvaluation are designed with this in mind, and we hope they will help you in a range of evaluative activities.

How is this different to what other people mean by 'evaluation'?

Not everyone defines evaluation in this way because of their diverse professional and educational backgrounds and training and organisational context. Be aware that people might define evaluation differently, and consider the implications of the labels and definitions that are used.

For example, some organisations use a definition of evaluation that focuses only on understanding whether or not an intervention has met its goals. However, this definition would not include a process evaluation, which might be used to check the quality of implementation and provide timely information to guide improvements. And it would not include a more comprehensive impact evaluation that considered unintended impacts (positive and negative) as well as intended impacts identified as goals.

Some organisations refer only to formal evaluations that are contracted out to external evaluators, which leaves out important methods for self-evaluation, peer evaluation and community-led evaluation.

A brief (4-page) overview that presents a statement from the American Evaluation Association defining evaluation as "a systematic process to determine merit, worth, value or significance".

The statement covers the following areas:

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Definition of evaluation

• appraisement
• judgement
• value judgment

Examples of evaluation in a Sentence

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'evaluation.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Word History

circa 1622, in the meaning defined above

Phrases Containing evaluation

• re - evaluation

Dictionary Entries Near evaluation

Cite this entry.

“Evaluation.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/evaluation. Accessed 18 Apr. 2024.

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• You need a careful evaluation by an experienced doctor .
• It is very difficult to make a detailed evaluation.
• The researchers turned up no credible evaluations at all.
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• interpretation
• job evaluation
• lucubration
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• review bomb

evaluation | Business English

Examples of evaluation, collocations with evaluation.

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to be so busy that you do not have time to do anything else

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Higher Learning Commission

•  | 
• Accreditation  | 
• Standard and Open Pathways  | 
• Standard Pathway  | 
• Comprehensive Evaluation  | 

Comprehensive Evaluation Visit

Comprehensive evaluations include an on-site visit by a peer review team to verify that the claims made by the institution in its submitted materials are accurate. Visits typically last 1 1/2 days. The team will remain in the area for an additional day of deliberations after the visit.

Note: Institutions are responsible for expenses related to the peer review team visit. These typically include travel, honoraria and facility expenses for the team members. HLC will send the institution an invoice for the visit.

Appointing the Peer Review Team

Approximately 4–6 months prior to the visit, HLC sets the peer review team and sends the team roster to the institution. When selecting reviewers to serve on the team, HLC staff members consider a variety of institutional factors, including the institution's size, highest degree level, Carnegie classification, mission and control. The roster provided to the institution includes information about each peer reviewer’s current institutional affiliation and position and areas of professional expertise.

In most cases, the team will include 5–7 peer reviewers, depending on institutional size and complexity. HLC may require a larger team for institutions with multiple academic units, multiple degree levels, corporate or state system relationships, or other complexities. HLC may assign additional reviewers as needed for other reasons based upon particular circumstances of the institution, such as multi-campus visits that include out-of-state or international locations.

Conducting the Visit

On-Site Visit Procedure

The team chair consults with the team and the institution’s leadership to craft a schedule that suits the context of the institution and the availability of individuals and groups.

The visit agenda is focused on activities best suited for in-person review and interaction. A typical visit includes:

• Customary meetings and reviews, including meetings with the institution’s leadership, board, and other key individuals and groups, such as those involved in preparing the materials for the comprehensive evaluation.
• One or more areas of focus determined by the team as needing additional attention.
• Open forum discussions on the Criteria for Accreditation with institutional stakeholders, including faculty, staff and students.
• Other evaluation as required or requested, such as multi-campus and embedded change reviews. (These additional reviews may be conducted prior to or as part of the visit.)

Many agenda variations are possible to ensure interaction with the appropriate groups. Some activities may require the attendance of the entire team, while other activities may be suitably conducted by a subset of the team. Therefore, some activities may overlap, while some activities may not.

The team will remain in the area to continue its deliberations for an additional day after the visit.

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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

View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure .

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

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.

When working with medical billing for insurance companies there can be a lot of confusion about the Medical Billing Terminology used.

One term that is commonly used is E&M visit, which is short form for Evaluation and Management Encounter.

This is essentially referring to a doctor’s visit, or a consultation (a visit requested by another physician or healthcare entity).

During a patient visit (sometimes known as an encounter) a physician examines the patient, documents his or her findings, and then determines the best course of action for treatment.

The Current Procedural Terminology (CPT) codes cover evaluation and management ( E&M) services, which clinicians use in billing for office and hospital visits. E&M visits are easily recognizable medical services such as a visit to urgent care, hospital admission, or daily rounds on people admitted to a hospital.

It is important to remember that insurance companies only pay for procedures that are medically necessary to the well-being of the patient. For that reason you must link each procedure billed to a medical diagnosis that supports the medical necessity for the procedure.

Whether a physician conducts an E&M visit or a consultation, he or she will report some sort of illness or disease-related term in the patient’s record, even if the problem is something as simple as the common cold.

Then you must ensure you are using the correct codes. It is important to understand the verbiage used in the record, as well as surgical procedures, evaluation and management procedures.

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Simplified guidelines for coding and documenting evaluation and management office visits are coming next year. Learn how to apply the guidelines to some common visit types.

CAROL SELF, CPPM, CPC, EMT, KENT MOORE, AND SAMUEL L. CHURCH, MD, MPH, CPC, FAAFP

Fam Pract Manag. 2020;27(6):6-11

Author disclosures: no relevant financial affiliations disclosed.

Editor's note: In its 2021 Medicare Physician Fee Schedule, CMS released new guidance regarding coding for prolonged E/M services. This article has been updated accordingly.

The American Medical Association (AMA) has established new coding and documentation guidelines for office visit/outpatient evaluation and management (E/M) services, effective Jan. 1, 2021. The changes are designed to simplify code selection and allow physicians to spend less time documenting and more time caring for patients. Physicians and other qualified health professionals (QHPs) will be able to select the level of office visit using either medical decision making (MDM) alone or total time (excluding staff time) on the date of service. In addition, the history and physical exam will be eliminated as components of code selection, and code 99201 will be deleted (code 99211 will not change). (See “ E/M coding changes summary .”)

To follow up on the previous FPM article detailing these changes (see “ Countdown to the E/M Coding Changes ,” FPM , September/October 2020), we have applied the 2021 guidelines to some common types of family medicine visits, and we explain below how documentation using a typical SOAP (Subjective, Objective, Assessment, and Plan) note can support the chosen level of service.

In each vignette, we've arrived at a code based only on the documentation included in the note. It's possible that a more extensive note could support a higher level of service by further clarifying the physician's decision making. But we've analyzed each case through an auditor's lens and tried not to make any assumptions that aren't explicitly supported by the note.

Starting in January, physicians and other qualified health professionals will be able to select the level of office visit using either medical decision making alone or total time (excluding staff time) on the date of service.

Medical decision making is made up of three factors: problems addressed, data reviewed, and the patient's risk. The highest level reached by at least two out of three determines the overall level of the office visit.

If the visit was time-consuming, but the medical decision making did not rise to a high level, the physician or qualified health professional may want to code based on total time instead.

MEDICAL DECISION MAKING (MDM)

Starting in January, physicians will be able to select the level of visit using only medical decision making, with a revised MDM table. (See the table at https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf .)

The four levels of MDM (straightforward, low, moderate, and high) will be maintained but will no longer be based on checkboxes or bullet points. The level of service will be determined by the number and complexity of problems addressed at the encounter, the amount and complexity of data reviewed and analyzed, and the patient's risk of complications and morbidity or mortality.

Here's what that looks like in practice:

STRAIGHTFORWARD MDM VIGNETTE

An established patient presents for evaluation of eye matting. The documentation is as follows:

Subjective: 16 y/o female presents with a 2-day history of bilateral eye irritation. She denies any fever or sick contacts. She started having a slight runny nose and cough this morning. She thinks the matting is a little better than yesterday. She wears daily disposable contacts but hasn't used them since her eyes have been bothering her. Her younger sibling has had similar symptoms for a few days.

Objective: Temperature 98.8, BP 105/60, P 58.

General: No distress. Does not appear ill.

HEENT: Mild bilateral conjunctival erythema without discharge. No tenderness over eye sockets. EOMI, PERRL.

Neck: No cervical lymph nodes palpated.

Lungs: Clear to auscultation.

Assessment: Viral conjunctivitis.

Plan: Reviewed likely viral nature of symptoms. Supportive and conservative treatment options reviewed, including eye cleaning instructions and contact lens precautions. Call the office if symptoms persist or worsen. Avoid use of contacts until symptoms resolve.

CPT code: 99212.

Explanation: Under the 2021 guidelines, straightforward MDM involves at least two of the following:

Minimal number and complexity of problems addressed at the encounter,

Minimal (in amount and complexity) or no data to be reviewed and analyzed,

Minimal risk of morbidity from additional diagnostic testing or treatment.

This is the lowest level of MDM and the lowest level of service physicians are likely to report if they evaluate the patient themselves (code 99211 will still be available for visits of established patients that may not require the presence of a physician).

In this fairly common scenario, the assessment and plan make it clear that the physician addressed a single, self-limited problem (“minimal” in number and complexity, per the 2021 MDM guidelines) for which no additional data was needed or ordered, and which involved minimal risk of morbidity.

Per the 2021 CPT guidelines, “For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated.” In this case, there is little risk of morbidity to this patient from the viral infection diagnosed by the physician.

It's possible the physician considered prescribing an antibiotic in this case, but decided against it. Options considered but not selected can be used as an element for “risk of complications,” but they should be appropriate and documented. There is no documentation in this note to indicate the physician made that decision. The documentation provided, therefore, does not support a higher level of service using MDM. But if the physician did make that decision and the ensuing conversation with the patient was time-consuming, the physician always retains the option to choose the level of service based on time instead.

LOW LEVEL OF MDM VIGNETTE

An established patient presents for follow-up for stable fatty liver. The documentation is as follows:

Subjective: 62 y/o female presents for follow-up of nonalcoholic fatty liver. She has no other complaints today and no other chronic conditions. She denies any fever, weight gain, swelling, or skin color changes. She also denies any confusion. She continues to work at her regular job and reports no difficulties there. She denies any unusual bleeding or bruising. Energy is good. Diagnosis was made three years ago, incidentally, on an ultrasound. Condition has been stable since the initial full evaluation.

Objective: BP 124/70, P 76, Temperature 98.7, BMI 26.

General: Well-appearing. Alert and oriented x 3.

Eyes: Sclera nonicteric.

Heart: Regular rate and rhythm; trace pretibial edema.

Abdomen: Soft, nontender, no ascites, liver margin not palpable.

Skin: No bruising.

Labs reviewed and analyzed: CBC normal, CMP with elevated AST (62 IU/ml) and ALT (50 IU/ml), PT/PTT normal.

Last ultrasound was 3 years ago.

Assessment: Nonalcoholic steatohepatitis, stable.

Plan: LFTs continue to be improved since initial diagnosis and 30-pound intentional weight reduction. Continue monitoring appropriate labs at 6-month intervals. Follow up in 6 months, or sooner if swelling, bruising, or confusion. Avoid alcohol. Continue weight maintenance. She is reassured her condition is stable and has no other questions or concerns, especially in light of her prior extensive education on the topic. I am arranging for hepatitis A and B vaccination. Discussed OTC medications, including vitamin E, and for now will avoid them.

CPT code: 99213

Explanation: Under the 2021 guidelines, low-level MDM involves at least two of the following:

Low number and complexity of problems addressed at the encounter,

Limited amount and/or complexity of data to be reviewed and analyzed,

Low risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one stable chronic illness, which is an example of an encounter for problems low in number and complexity. The risk of complications from treatment is also low. The “Objective” section indicates review of three lab tests, which qualifies as a moderate amount and/or complexity of data reviewed and analyzed. However, the level of MDM requires meeting two of the three bullets above, so the overall level remains low for this vignette.

MODERATE LEVEL OF MDM VIGNETTE

An established patient with obesity and diabetes presents with new onset right lower quadrant pain. The documentation is as follows:

Subjective: 42 y/o female presents for evaluation of 2 days of abdominal pain. She has a history of Type 2 diabetes, controlled. Pain is moderate, 6/10 currently, and 10/10 at worst. The pain is intermittent. The pain is located in the back and right lower quadrant, mostly. She denies diarrhea or vomiting but does note some nausea. She denies fever. She denies painful or frequent urination. She is sexually active with her spouse. She has had a hysterectomy due to severe dysfunctional bleeding. She has not tried any medication for relief. No position seems to affect her pain. She has not had symptoms like this before. Home glucose checks have been in the 140s fasting. Her last A1C was 6.9% two months ago. Family history: Sister with a history of kidney stones.

Objective: BP 160/95, P 110, BMI 36.1.

General: Appears to be in mild to moderate pain. Frequently repositioning on exam table.

HEENT: Moist oral mucosa.

Abdomen: Mild right-sided tenderness. No focal or rebound tenderness. Normal bowel sounds. No CVA tenderness. No suprapubic tenderness. No guarding.

UA with microscopy: 3 + blood, no LE, 50–100 RBCs, 5–10 WBCs.

CBC, CMP, CT stone study ordered stat.

Assessment: Abdominal pain – suspect renal stone. Also consider cholecystitis, gastroparesis, gastroenteritis, appendicitis, and early small bowel obstruction.

Diabetes, type 2, controlled.

Obesity – this is a risk factor for gall-bladder problems, but still favor renal stone.

Plan: Ketorolac 60 mg given in office for pain relief. Hydrocodone/APAP prescription for pain relief. Discussed at length suspicion of renal stone. Will plan lab work and pain control and await CT stone study. Urine sent to reference lab for microscopy. Drink plenty of fluids. Urine strainer provided. Call the office if worsening or persistent symptoms. Await labs/CT for next steps of treatment plan. Will follow up with her if urology referral is indicated.

CPT code: 99214

Explanation: Under the 2021 guidelines, moderate level MDM involves at least two of the following:

Moderate number and complexity of problems addressed at the encounter,

Moderate amount and/or complexity of data to be reviewed and analyzed,

Moderate risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one undiagnosed new problem with uncertain prognosis (abdominal pain) and two stable chronic conditions (diabetes and obesity). Either one (the new problem with uncertain prognosis or two stable chronic conditions) meets the definition of a moderate number and complexity of problems under the 2021 MDM guidelines. But they do not meet the threshold of a high number and complexity of problems, even when combined.

The physician reviews or orders a total of four tests, which again exceeds the requirements for a moderate amount and/or complexity of data, but doesn't meet the requirements for the high category.

The prescription drug management is an example of moderate risk of morbidity. One might argue that the risk of morbidity is high because renal failure could result from a major kidney stone obstruction. But even then the overall MDM would still remain moderate, because of the number and complexity of problems addressed and the amount and/or complexity of data involved.

HIGH LEVEL OF MDM VIGNETTE

An established patient with a new lung mass and probable lung cancer presents with a desire to initiate hospice services and forgo curative treatment attempts. The documentation is as follows:

Subjective: 92-year-old male presents for follow-up of hemoptysis, fatigue, and weight loss, along with review of his recent chest CT. He reports moderate mid-back pain, new since last week. Appetite is fair. He denies fever. He continues to have occasional cough with mixed blood in the produced sputum.

Objective: BP 135/80, P 95, Weight down 5 pounds from 2 weeks ago, BMI 18.5, O2 sat 94% on RA.

General: Frail-appearing elderly male. No distress or shortness of breath. Able to speak in full sentences.

HEENT: No palpable lymph nodes.

Lungs: Frequent coughing and diffuse coarse breath sounds.

Heart: Regular rate and rhythm.

Ext: No extremity swelling.

MSK: Moderate tenderness over multiple thoracic vertebrae.

CT shows large right-sided lung mass suspicious for malignancy, along with a moderate left-sided effusion. Lytic lesions seen in T6-8.

Assessment: Lung mass, suspect malignancy with bone metastasis.

Plan: After extensive review of the findings, the patient was informed of the likely poor prognosis of the suspected lung cancer. We reviewed his living will, and he reiterated that he did not desire life-prolonging measures and would prefer to allow the disease to run its natural course. He also declines additional testing for diagnosis/prognosis. A shared decision was made to initiate hospice services. Specifically, we discussed need for oxygen and pain control. He declines pain medications for now, but will let us know. He and his son who was accompanying him voiced agreement and understanding of the plan.

CPT code: 99215

Explanation: Under the 2021 guidelines, high level MDM involves at least two of the following:

High number and complexity of problems addressed at the encounter,

Extensive amount and/or complexity of data to be reviewed and analyzed,

High risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one acute or chronic illness or injury (suspected lung cancer) that poses a threat to life or bodily function. This is an example of a high complexity problem in the 2021 MDM guidelines. The physician reviewed one test (CT), so the amount and/or complexity of data is minimal. A decision not to resuscitate, or to de-escalate care, because of poor prognosis is an example of high risk of morbidity, and the physician has clearly documented that in the plan portion of the note. Consequently, even though the amount and/or complexity of data is minimal, the overall MDM remains high because of the problem addressed and the risk involved.

Under the new guidelines, total time means all time (face-to-face and non-face-to-face) the physician or other QHP personally spends on the visit on the date of service. Examples include time spent reviewing labs or reports, obtaining or reviewing history, ordering tests and medications, and documenting clinical information in the EHR.

The AMA has also created a new add-on code, 99417, for prolonged services. It can be used when the total time exceeds that of a level 5 visit – 99205 or 99215. (See “ Total time plus prolonged services template .”)

TIME-BASED CODING VIGNETTE

An established patient presents with a three-month history of fatigue, weight loss, and intermittent fever, and new diffuse adenopathy and splenomegaly. The documentation is as follows:

Subjective: 30-year-old healthy male with no significant PMH presents with a three-month history of fatigue, weight loss, and intermittent fever. He travels for work and has been evaluated in several urgent care centers and reassured that he likely had a viral syndrome. Fevers have been as high as 101, but usually around 100.5, typically in the afternoons. Testing for flu and acute mono has been negative. He denies high-risk sexual behavior and IV drug use. He denies any sick contacts. He has not had vomiting or diarrhea. He has not had any pain. He denies cough.

Objective: BP 125/80, P 92, BMI 27.4.

General: Well-nourished male, no distress.

HEENT: No abnormal findings.

Lungs: Clear.

Heart: No murmurs. Regular rate and rhythm.

Abdomen: Soft, non-tender, moderate splenomegaly.

Skin: Multiple petechia noted.

Lymph: Multiple cervical, axillary, and inguinal lymph nodes that are enlarged, mobile, and non-tender.

Assessment: Weight loss, lymphadenopathy, and splenomegaly

Plan: Prior to the visit, I spent 15 minutes reviewing the medical records related to his recent symptoms and various urgent care visits. We reviewed the differential at length to include infectious disease and acute myelodysplastic condition. I have ordered stat blood cultures, TB test, EBV titers, echo, and CBC. The pathologist called to report concerning findings on the CBC for likely acute leukemia. I called the patient to inform him of his results and need for additional testing. I also discussed the patient with oncology and arranged a follow-up visit for tomorrow. I spent a total of 92 minutes with record review, exam, and communication with the patient, communication with other providers, and documentation of this encounter.

CPT Codes: 99215 and 99417 x 3.

Explanation: In this instance, the physician has chosen to code based on time rather than MDM. The physician has documented 92 minutes associated with the visit on the date of service, including time not spent with the patient (e.g., time spent talking with the pathologist and time spent in documentation). According to the 2021 CPT code descriptors, 40–54 minutes of total time spent on the date of the encounter represents a 99215 for an established patient.

The 2021 CPT code set also notes that for services of 55 minutes or longer, you should use the prolonged services code, 99417, which can be reported for each 15 minutes beyond the minimum total time of the primary service (99215). The difference between the 92 minutes spent by the physician and the 40-minute minimum for 99215 is 52 minutes. There are three full 15-minute units of 99417 in those 52 minutes, so the physician may report three units of 99417 in addition to 99215. CPT 2021 instructs you to not report 99417 for any time unit less than 15 minutes, so the seven remaining minutes of prolonged service is unreportable.

Note that if this had been a new patient, the physician would only be able to report two units of 99417 in addition to 99205. Though the elements of MDM do not differ between new and established patients, the total time thresholds do. The range for a level 5 new patient is 60–74 minutes.

FINAL THOUGHTS

CPT does not dictate how physicians document their patient encounters. As illustrated above, a standard SOAP note can be used to support levels of MDM (and thus levels of service) under the 2021 guidelines.

Physicians who want to further solidify their documentation in case of an audit may choose to make the elements of MDM more explicit in their documentation. This could be particularly helpful for documenting the level of risk, which is the least clearly defined part of the MDM table and potentially most problematic because of its inherent subjectivity. Stating the level of risk and giving a rationale when possible allows a physician to articulate in the note the qualifying criteria for the submitted code. For example, going back to our vignette of moderate MDM, the physician could note in the chart, “This condition poses a threat to bodily function if not addressed, due to acute kidney injury for an obstructive stone.”

It is also worth noting that much of the note in each case is for purposes other than documenting the level of service. For instance, with history and physical exam no longer required, the subjective and objective portions of the note are recorded primarily for continuity or quality of care rather than to justify the level of service. This provides some administrative simplification. What's in the note will become more about what is needed for medical care and less about payment justification under the new guidelines. That's a plus for primary care.

We hope these examples are helpful as you prepare to implement the 2021 CPT changes. You can also visit https://www.aafp.org/emcoding for more resources and information.

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• International

Trump hush money trial

Israel-Hamas war

April 17, 2024 - Israel-Hamas war

By Kathleen Magramo, Antoinette Radford and Tori B. Powell, CNN

Our live coverage of Israel's war on Hamas in Gaza has moved  here .

Death toll from strike on central Gaza's Al-Maghazi refugee camp rises to 14, hospital officials say

From CNN's Jennifer Hauser

The death toll from an Israeli airstrike that targeted the Al-Maghazi refugee camp has risen to 14, including 8 children, according to Al-Aqsa hospital officials.

The airstrike hit the refugee camp in central Gaza on Tuesday, with initial reports saying 13 people — including seven children — were among those killed.

The Israeli military said the incident is under review.

Footage of the strike: Graphic video, obtained exclusively by CNN from eyewitness Nihad Owdetallah, showed several casualties scattered on the floor, including children, with blood streaming around the area.

In the video, dozens of people appear to be running around in panic, screaming and trying to count and carry the dead bodies. A foosball table covered in dust is seen among the dead bodies.

Footage shot for CNN from inside Al-Aqsa Martyrs Hospital showed a continuous flow of casualties and injured people being ushered in, as the emergency room is crowded with patients, including several wounded children, crying out on the floor. Family members were seen crowding over their loved one’s dead bodies, kissing them, holding onto them and sobbing.

Qatar will conduct a "comprehensive evaluation" of its mediation role in sensitive negotiations

From CNN’s Hamdi Alkhshali, Raja Razek and Larry Register in Atlanta

Qatari Prime Minister Sheikh Mohammed bin Abdulrahman Al Thani expressed concerns Wednesday over the current state of international mediation efforts led by Qatar to help reach an agreement on the release of hostages and a ceasefire between Israel and Hamas in Gaza.

Al Thani, who is also Qatar's foreign minister, criticized the misuse of Qatar's efforts for “narrow political” gains by some involved, undermining the broader goal of peace and humanitarian relief, “which required the State of Qatar to conduct a comprehensive evaluation.”

He emphasized the sensitivity of the ongoing talks and highlighted the challenges faced in bridging gaps between conflicting parties. He also pointed out the inconsistency between private assurances and public statements by involved parties, describing such actions as counterproductive. 

While the Qatari leaders did not point anyone out by name, the comments followed a statement by US Rep. Steny Hoyer on Monday that said if Qatar fails to apply pressure on Hamas to reach an agreement on a deal to release hostages and establish a temporary ceasefire, “the United States must reevaluate its relationship with Qatar.”

On Tuesday Qatar’s Embassy to the US in Washington issued a statement saying it was surprised by Hoyer’s remarks, adding that while the country shares the congressman's frustrations, it does not control Israel or Hamas.

It's past midnight in Gaza. Here's what you should know

From CNN staff

More than 13,800 children have been killed in the Gaza Strip since the start of the war on October 7, according to United Nations Children's Fund (UNICEF) Executive Director Catherine Russell.

Additionally, "one child is injured or dies every 10 minutes" in Gaza, according to the United Nations Entity for Gender Equality and the Empowerment of Women. The statement added that more than 10,000 women have been killed in Gaza since the war began, 6,000 of whom left 19,000 orphaned children behind.

CNN cannot independently verify death numbers due to lack of access to the strip.

Here are other headlines you should know:

• Fatal IDF operation: The Israeli military claims to have killed and arrested several militants during an operation in the civilian area of Beit Hanoun in the northeastern Gaza Strip. The Israel Defense Forces said it had raided a building complex that included two schools after receiving "intelligence that terrorists from the Hamas and Islamic Jihad terrorists organizations were located in the building and using civilians present there as human shields." CNN is not able to independently confirm the claims made by the IDF.
• Hezbollah targets: Israeli fighter jets struck alleged Hezbollah targets in southern Lebanon after 18  Israelis were injured  when the Iran-backed Lebanese militant group attacked a village in northern Israel. The IDF said three civilians were among the 18 people injured in the attack, the rest being soldiers.
• Response to Iran's attack: Israel’s Finance Minister Bezalel Smotrich said Israel’s response to Iran’s attack should inflict a “disproportionate toll” and “rock Tehran” to deter Iran from future strikes. Also, French President Emmanuel Macron called for widening sanctions against Iran that can also target industries supporting missiles and drones production.
• Aid to Gaza: The first shipment of aid to the Gaza Strip to be delivered into Ashdod Port was transferred to Gaza Wednesday, according to the Israeli military. The IDF said eight World Food Programme (WFP) trucks carrying flour entered via the Kerem Shalom Crossing after being inspected at Ashdod.

First aid shipment to Gaza through Ashdod Port enters the Gaza Strip

From CNN’s Benjamin Brown

The first shipment of aid to the Gaza Strip to be delivered into Ashdod Port was transferred to Gaza Wednesday, according to the Israeli military. 

The Israel Defense Forces said eight World Food Programme (WFP) trucks carrying flour entered via the Kerem Shalom Crossing after being inspected at Ashdod.

Israel earlier this month announced its decision to facilitate aid deliveries via the port.

At the time, US Secretary of State Antony Blinken welcomed the development but said the “real test” would be to see whether aid was “effectively reaching people who it needed throughout Gaza.”

CNN has reached out to the WFP for comment.

Israeli military says it killed and arrested militants during operation in northern Gaza

From CNN's Benjamin Brown

The Israeli military claims to have killed and arrested several militants during an operation in the civilian area of Beit Hanoun in the northeastern Gaza Strip.

The Israel Defense Forces said it had raided a building complex that included two schools after receiving "intelligence that terrorists from the Hamas and Islamic Jihad terrorists organizations were located in the building and using civilians present there as human shields."

CNN is not able to independently confirm the claims made by the IDF.

The IDF said it told civilians to leave the building before entering during its joint operation with the Israel Security Agency, Israel's domestic security agency, also known as Shin Bet or Shabak.

What Gazans told CNN: People living in the area said Israeli military vehicles began an operation there on Monday afternoon, firing shots and rounds of artillery shelling. Local residents said that Israeli forces had surrounded three schools early Tuesday morning, including one where hundreds of people had been sheltering. They ordered people to leave the schools and detained dozens of men, including some elderly people and teenagers over the age of 15, according to residents. An elderly woman who had been sheltering in one of the schools said Israeli soldiers came in the middle of the night and arrested several men and women.

Nearly 14,000 children killed in Gaza since war began, according to UNICEF

From CNN's Hande Atay Alam

More than 13,800 children have been killed in Gaza Strip since the start of the war on October 7, according to United Nations Children's Fund (UNICEF) Executive Director Catherine Russell.

"Thousands have been injured and thousands more are on the brink of famine," she said during a news conference in New York, according to a statement from her organization.

In a separate statement, the United Nations Entity for Gender Equality and the Empowerment of Women said that "one child is injured or dies every 10 minutes" in Gaza. The statement added that more than 10,000 women have been killed in Gaza since the war began, and 6,000 of them left 19,000 orphaned children behind.

UNICEF communication specialist Tess Ingram, who recently visited Gaza, said during a news conference in Geneva on Tuesday that what struck her was the number of wounded children she saw.

"Not just in the hospitals, but on the streets, in their makeshift shelters, going about their now permanently altered lives," she said.

German airline says it will avoid Iranian airspace following weekend attacks on Israel

Germany’s Lufthansa airline has announced it will extend its suspension of flights to the capitals of Iran and Lebanon due to the security situation in the region.

Flights to Tehran and Beirut will remain canceled up to and including April 30, Lufthansa said in a statement Wednesday. The airline also said it would continue not to use Iranian airspace until the end of the month.

“The Lufthansa Group is continuously monitoring and assessing the security situation in the Middle East and is in close contact with the authorities,” the airline said.

Lufthansa first suspended flights to the Iranian capital of Tehran last week and had already once extended its suspension.

French president calls for widening sanctions against Iran

From CNN’s Joseph Ataman

French President Emmanuel Macron called for widening sanctions against Iran that can also target industries supporting missiles and drones production.

“Our duty is to broaden these sanctions,” he said Wednesday while in Brussels for a meeting between European leaders.

His comments comes after more than 300 projectiles – including around 170 drones and over 120 ballistic missiles – were fired toward Israel in a retaliatory aerial attack by Iran on Saturday.

Iranian drones have been widely used in other conflicts, including by Russia against Ukrainian infrastructure targets.

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Supreme Court allows enforcement of Idaho ban on gender-affirming care for transgender minors

WASHINGTON — A divided Supreme Court on Monday allowed Idaho to mostly enforce a law that bans gender-affirming health care for transgender teenagers.

Granting an emergency request filed by Idaho officials, the court said the law enacted, which was last year, could go into effect statewide but cannot be applied against the two plaintiffs who challenged it.

The court's three liberal justices objected to the decision, saying the law should have remained blocked in full.

U.S. District Court Judge Lynn Winmill ruled in December that the state could not enforce the law while litigation continues. The state has appealed to the San Francisco-based 9th U.S. Circuit Court of Appeals, which has yet to rule.

The law, like measures enacted by other states, prevents the use of what Winmill called “generally accepted medical treatment” for transgender minors, including puberty blockers, hormone therapy and surgical procedures.

Officials subsequently turned to the Supreme Court, which has a 6-3 conservative majority, saying that the injunction was too broad and that the law should be blocked only for the two plaintiffs in the lawsuit.

Conservative Justice Neil Gorsuch, in an opinion explaining his vote to allow the law to be enforced, said the lower court had gone “much further” than needed in putting the entire law on hold. He noted, for example, that Winmill blocked a provision that barred surgery “even though no party before the court had sought access to those surgeries.”

The Supreme Court's intervention should be viewed as a "welcome development," Gorsuch said.

In a dissenting opinion, liberal Justice Ketanji Brown Jackson said that the case “presents numerous reasons for exercising restraint” but that instead, the court had decided to step in and was guilty of "micromanaging" the lower courts.

Lawyers for the plaintiffs, two transgender teens, said it was necessary that the judge blocked the entire law because if it went into effect, it might imperil all gender-affirming health care in the state.

The American Civil Liberties Union, which represents the teens, said in a statement that the decision was an "awful result for transgender youth and their families across the state" that "allows the state to shut down the care that thousands of families rely on while sowing further confusion and disruption."

Idaho Attorney General Raul Labrador, a Republican, said in a statement that the state had a duty to protect children from "life-altering drugs and procedures."

He said minors diagnosed with gender dysphoria "deserve love, support, and medical care rooted in biological reality."

The plaintiffs, named in court papers only as Pam Poe and Jane Doe, say the law, called the Vulnerable Child Protection Act, among other things violates the Constitution's 14th Amendment by discriminating on the basis of sex.

Poe is a 16-year-old transgender girl who has been prescribed puberty blockers. Doe is a 17-year-old transgender girl who was also prescribed puberty blockers and has begun hormone therapy.

Both say medical treatment has improved their mental health.

More than 20 states have enacted similar bans , according to the Movement Advancement Project, an LGBTQ rights think tank.

The Supreme Court is likely to weigh in on the broader legal question in the future as challenges to the laws make their way through the court system.

In the coming weeks, appeals concerning similar laws in Tennessee and Kentucky will be up for consideration by the justices.

Lawrence Hurley covers the Supreme Court for NBC News.