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1 Medical Billing Made Easy Presents Optimizing Office Visits for Preventive Services Beginning now Today s Program Introduction Presentation: Betsy Nicoletti, M.S., CPC Kareo Special Offer: Alyse Giannini, Account Executive, Kareo Questions 3 How to Participate Today Arrow = Open/close your panel Questions = Submit text questions Follow-up with video link within 24 hours 1

2 Optimizing Office Visits for Preventive Services Betsy Nicoletti, M.S., CPC What Are Preventive Services? Age and gender appropriate history and exam Risk factor reduction, anticipatory guidance Referral/provision for screening tests Immunizations Patients with group health insurance that has renewed since Sept have first dollar coverage of services with an A or B rating from the US Preventive Task Force More patients will have full coverage without co-pay or deductible for annual exams 7 2

3 Correct appointment type ensures correct time, that the medical assistant opens the correct template/puts the right forms on the chart Prevents that Oops moment near the end of the visit when patient says, This was supposed to be my physical Reduces phone calls after the visit, The insurance company says you coded it wrong 8 Lab tests done in the office Administration of vaccines; vaccines if purchased Venipuncture Hearing and eye tests Problem-oriented visit if documented History documents symptoms/status A/P documents plan for problem visits Patient will be charged a co-pay/deductible Insurance coverage for second E/M varies 9 Finally, an annual wellness exam for Medicare patients! No co-insurance, no deductible Courtesy of health care reform bill passed in March of 2010 Different definition

4 G0402: Welcome to Medicare Visit (IPPE) G0403: Screening EKG at time of IPPE G0438: Annual Wellness Visit, (AWV) including personalized prevention plan services, first visit G0439: Annual Wellness Visit, including personalized prevention plan services, subsequent visit 11 Code Work RVUs Total RVUs G0402 Welcome to Medicare G0438 Initial i Annual Wellness Visit G0439 Subsequent Annual Wellness Visit The Welcome to Medicare visit is the covered wellness service during that time period Once in a lifetime benefit Also called the Initial Preventive Physical Exam, IPPE

5 Patients who have been on Medicare for over 12 months and have not received either an IPPE or an annual wellness exam in past 12 months Can only be performed once per patient, not per physician New or established patients Patients who receive care in more than one state or place 14 From July 1, 2011 till June Jock is eligible for his 30, 2012, he is eligible initial annual wellness visit only for the Welcome to after Feb Medicare visit. (IPPE) Jock is eligible for his Not eligible for annual subsequent wellness visits wellness visit Receives IPPE on Feb. 5, 2012 Eligible for initial AWV 366 days later 366 days later, and every year thereafter IPPE first year of enrollment Wellness visits after that 15 After January 1, 2011, he is eligible for his initial annual wellness visit Has AWV June 23, 2012 Never had an IPPE wasn t available when he enrolled Eligible for subsequent 366 days later, and every year after that Starts with initial wellness visit Subsequent wellness visits after that

6 Medical, family and social history, including medications, use of vitamins and supplements Screening for depression using accepted tool Screening for activities of daily living, safety, asking about hearing More 17 Physical exam: height, weight, BMI, BP, visual acuity Screening EKG if needed With patient consent, end of life planning Counseling, education and referral based on above WRITTEN plan given to patient for Medicare covered preventive services 18 Personalized prevention plan services Starting : Health Risk Assessment Like the IPPE: the initial is a once in a lifetime benefit Subsequent wellness visits yearly

7 Effective January 1, 2012 a health risk assessment must be part of the AWV CMS expects the patient to complete this before physician sees patient, or will complete with staff CMS does not think it will require additional physician/ NP/PA time Slight increase in RVUs 20 An evaluation tool designed to provide a systematic approach to obtaining accurate information about the patient s health status, injury risk, modifiable risk factors and urgent health needs. Completed prior to, or as part of, an annual wellness visit. The information from the HRA is reflected in the personalized prevention plan that is created for the individual. 21 Taking or updating individual s medical and family history Establishing list of current providers and suppliers of medical care PE: height, weight, BMI calculation (or waist circumference), BP and other routine measurements as deemed appropriate

8 Detection of any cognitive impairment that the individual may have By direct observation, with consideration of information from medical records, patient reports, concerns raised by family members Review potential for depression based on use of appropriate screening instrument 23 Review of individual s functional ability and level of safety Based on direct observation, or use of screening questionnaire regarding: Hearing impairment Ability to successfully perform activities iti of daily living Fall risk Home safety 24 Written screening schedule, such as a checklist, for the next 5-10 years based on: Recommendations of the US Preventive Task Force and Advisory Committee on Immunization Practices, and The Individual s health status, screening history, and age-appropriate covered Medicare services

9 A list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway, including mental health conditions or risk factors or conditions identified through this visit or the IPPE AND A list of treatment options and their associated risks and benefits 26 Furnishing of personalized health advice and referral, as appropriate to health education or preventive counseling programs aimed at reducing identified risk and improving self management including weight loss, smoking cessation, fall prevention and nutrition 27 And, any other element determined as appropriate by the Secretary of Health and Human Services through the National Coverage Determination process

10 Update medical and family history Update current providers PE: weight, BP and other routine measurements as deemed appropriate (Height and BMI not required ) Detection of cognitive function 29 Update the written screening schedule established at initial visit Update the list of risk factors and conditions for which treatment was recommended Furnish personalized health advice and referral, as appropriate to health education or preventive counseling programs aimed at reducing identified risk and improving self management including weight loss, smoking cessation, fall prevention and nutrition 30 Visits are not defined as new or established, but as initial and subsequent The initial is very like the IPPE For newly enrolled Medicare patients, (first 12 months) the IPPE must be done first Patients may expect the service

11 These are CPT defined as an age/gender appropriate history and physical exam with risk factor reduction, anticipatory guidance, provision of or referral for immunization and diagnostics If you perform a typical preventive medicine service, it is not covered by Medicare, you ll have to bill the patient! 32 Yes, bill for other covered preventive services, such as the pelvic and breast exam Remember frequency limits and diagnosis code requirements Problem oriented office visit Smoking cessation (G0436, G0437) require time is documented in the medical record, and is in addition (not part of) the other service 33 Inspection and palpation of the breasts for lumps, tenderness, symmetry or nipple discharge Digital rectal exam Pelvic exam including: External genitalia Urethral meatus Bladder Urethra Vagina Cervix Uterus Adnexa/parametria Anus and perineum

12 G0101: be sure breast is one of the seven elements, and there are seven elements G0101: Work RVU.45 total RVUs 1.10 Use Q0091 only for obtaining a screening pap smear Q0091: Work RVU.37 total RVUs 1.31 (All RVUs are non-facility, i.e. physician office) 35 Allowed for a medically necessary, significant and separately identifiable service Append modifier 25 to E/M service When selecting a level of service, no part of the AWV documentation can be used to select the level of service My opinion: is not a significant separate service; would also be unusual 36 IPPE and AWV, use V70.0 For pelvic and breast exam: use screening diagnoses V15.89 for high risk annual, V76.2, V76.47, V72.31 for bi-annual For smoking cessation, use tobacco abuse For problems, use the medical problem For colorectal screening: use V76.51 special screening for malignant neoplasms colon

13 Code Description Work RVU G0442 Annual alcohol misuse screening, 15 minutes Total RVU G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes G0444 Annual depression screening, 15 minutes G0447 Face-to-face behavioral counseling for obesity, 15 minutes Alcohol screening and misuse counseling must by primary care clinicians in a primary care setting Annual depression screening must be performed in primary care setting. Staff may do part of the screening. Obesity counseling: allowed weekly for one month, biweekly for months 2-6 and monthly if patient has lost 3 kg in weeks 7-12 Notice the payment amounts 39 USPTF stopped making recommendations about vaccines in 1996, now another body makes those recommendations Statute doesn t allow CMS to use CDC s recommendations to pay for herpes zoster or hepatitis or other vaccines under Part B. If covered, will continue to be a Part D (pharmacy) benefit

14 New Medicare benefit that patients will expect CMS believes it will help to keep patients healthy Can be a source of revenue for your practice if you: Review the requirements Develop or use forms from specialty societies that meet the requirements Have a process in place 41 Schedule the right appointment type Bill for other services on the same day Be careful about an office visit on the same day 42 Thank You/Contact Betsy Nicoletti, M.S., CPC Medical Practice Consulting Speaker, Trainer, Author betsy@vermontel.netnet These handouts may not be reproduced without the written consent of the speaker

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