Medicare Wellness Meggan Robinson, DO MAOFP Spring Update 4/23/16
Objectives History of Medicare Wellness Exam Identify the goals of the Wellness exam Differentiate the different types of Wellness exams Learn what is included and covered? Review basic preventive guidelines supported by the USPSTF Codes for billing
I have no disclosures! Disclosures
Affordable Care Act Signed into law March 23, 2010 Insurance plans must provide coverage for preventive care and medical screenings rated A or B by the USPSTF. Insurers are prohibited from charging copays, co-insurance, or deductibles for these services Jan 1, 2011-Medicare offers Annual Wellness Visits
Goals of Wellness Visits Health Promotion Disease Prevention Detection Among adults 65 & older, only 33% of women & 40% of men are UTD with all age-specific recommended services.
Types of Wellness Visits 1. Welcome to Medicare preventive visit IPPV-Initial Preventive Physical Exam G0402 2. Yearly Wellness Visits Initial AWV (Annual Wellness Visit)- G0438 Subsequent AWV- G0439
Who s Eligible? All people with Medicare Part B are covered. If additional tests or services are ordered during a wellness visit that are not covered under preventive benefits, pt may have to pay coinsurance or deductible may apply.
Welcome To Medicare What s Included Review of medical, family, social history Height, Weight, Blood pressure, BMI Vision Test Depression Screen Level of Safety Advanced Directives Counseling education/preventive services Formulated plan: including screenings, immunizations, other preventive services
Annual Wellness Visit What s included Pt to complete HRA Height, weight, BMI, Blood Pressure Review medical, social, family history Develop an undated list of providers and prescriptions Depression Screen Functional Ability and Level of safety Detection of cognitive impairment Counseling/Education Formulated Plan: Including screening, immunizations, preventive services
Where is the Physical Exam? Height, Weight, BMI, and blood pressure Other routine measurements as deemed appropriate based on medical and family history (medicare.gov) Other factors deemed appropriate based on medical and social history and current clinical standards (cms.gov)
HRA Collects self reported information from the beneficiary At a minimum collects: Demographic Data Self reported health Psychosocial and Behavioral Risks ADLs
Case 1 65 yo AA M who is presenting for his Welcome to Medicare Visit PMH: HTN, DMII Meds: Metformin 500mg BID, Lisinopril/HCTZ, ASA Social Hx: Smoker 1ppd x 40 years-quit 5 years ago, Etoh-1-2 beers/week FH: CAD, DM Vitals: Height 5ft 7in, Weight 193lb, BMI-30, BP 112/70
Review Hx Review Mr. Wells medications, social history, family history Hospitalizations Diet/Exercise Functional Ability-Denies hearing difficulties/unlimited ADLs Fall Risk Factors-Antihypertensive use, Loose Rugs
Depression/Cognitive Impairment Screen PHQ-2 Over the past 2 weeks, Have you felt down, depressed, or hopeless? Over the past 2 weeks, Have you felt little interest or pleasure doing things? Pt denies difficulty learning/retaining new info, difficulty with behavior or language, reasoning or complex tasks.
Advance Directives Living will, DPOA, Advance Directives? Reviewed end of life decisions with pt
Physical Exam Vitals Vision Test- Acuity 20/50 b/l Get up and Go? Your choice of further exam
Once in a lifetime screening EKG-1 time screening Diagnostic EKGs are different AAA Screening- For those at risk 1. Family History 2. Male age 65-75 and have smoked 100 cigarettes in lifetime
Preventive/Screening Services Cardiovascular Screening Lipid panel every 5 years Diabetes Screening-Cover 2 per year If there are risk factors- HTN, Dyslipidemia, Obesity, History of elevated BG Or if 2 or more of the following: Age > 65 Overweight Family Hx DM Gestational DM or baby > 9lb
Preventive/Screening Services Lung Cancer Screening Low dose CT scan- 1/year Must meet ALL criteria 55-77yo Asymptomatic (no signs or symptoms of lung ca) Current smoker or quit in the past 15 years 30 pack year smoking history
Preventive/Screening Services Colon Cancer Screening If normal risk-colonoscopy every 10 years for 50 year old and greater Flex sig every 3 years Barium enema every 3 years FOB every year Stool DNA testing-every 3 years for those that meet ALL criteria
Preventive/Screening Services Colon Cancer Screening Stool DNA testing criteria: 1. 50-85yo 2. No signs or symptoms of colorectal disease (Lower abd pain, blood in stool, +FOB) 3. Average risk- No history of adenomatous polyps, CRC, or IBD. No family history of hereditary conditions.
Preventive/Screening Services Prostate Cancer Screening PSA every 12 months DRE every 12 months
Preventive/Screening Services Immunizations Influenza- 1 per season Shingles Vaccine- No covered under Part A or B Tdap-Not covered under Part A or B Pneumococcal vaccines- Prevnar (PCV13) and Pneumovax (PPSV23)- both covered and recommended for age >65. Hep B-Covered for those at moderate to high risk.
Preventive/Screening Services STI screening Chlamydia, gonorrhea, syphilis, HIV, Hep B screenings are covered yearly for sexually active adults at risk for STI s.
Case 1 Recap Mr. Wells was encouraged to continue his healthy diet and active lifestyle. Fall prevention discussed. He was advised to fill out Advance Directive AAA screening and EKG done today Influenza and Prevnar immunizations given Lipid profile and PSA ordered UTD on colonoscopy, Declined further Lung cancer screenings Referred to Eye doctor for annual HTN/DM eye exam
Case 1 Recap Billed G0402 Diagnosis Code of V70.0
Case 2 67 yo Caucasian F who presents for her AWV PMH: Osteoporosis, OA Meds: Fosamax, Tramadol Social Hx: 5 pack year smoking hx, no etoh, no illicits Family Hx: DM, HTN, Stroke, CAD Pt has new complaint of elbow pain today. Vitals: 5ft 3in, 143lb, BMI 25, BP 140/46
Review Hx Review Mrs. Robertson s medications, social, family history Hospitalizations Diet/Exercise Depression Screen-Negative Functional Ability and Level of Safety-Normal ADLs Cognitive Impairment-Denies Update Advance Directive if needed
Physical Exam Vitals Vision Test? Get up and go? Your choice of physical exam.
Preventive/Screening Services Once in a lifetime screening AAA EKG
Preventive/Screening Services Bone Mineral Density Testing Covered every 24 months (more often if medically necessary) At risk: Woman who are estrogen deficient & at risk Any person with an xray-osteoporosis/osteopenia/fractures Any person taking chronic steroids or planning to begin Dx of primary hyperparathyroidism Monitor to see if their osteoporosis drug is working
Preventive/Screening Services Cervical Cancer Screening Covers cervical/vaginal/clinical breast exams Covered every 2 years for all women Covered every 1 year for women at high risk for cervical cancer or vaginal cancer
Preventive/Screening Services Mammogram Every 1 year (for women 40 & older) Diagnostic mammogram when necessary but 20% deductible may apply
Preventive/Screening Services Mrs. Robertson Screening Checklist: Cardiovascular/Diabetes screen-lipid Panel Colonoscopy-Completed in 2010 Lung cancer screening-not Indicated Immunizations-Influenza due, Pneumovax given at 65-Prevnar can be given.
Case 2 Recap Mrs. Robertson advised to continue healthy diet. Activity will be addressed after PT following knee surgery. Mammogram and BMD ordered Influenza and PCV13 (Prevnar) given Rx for Zostavax given Discussed fall prevention No referrals needed. Pt will follow up for elbow pain.
Case 2 Recap Billed G0438 Diagnosis code of V70.0
FAQs Is an annual wellness visit (AWV) the same as a yearly physical? No. Medicare does not cover routine physical exams.
FAQs Can I bill an EKG & AWV on the same date of service? You may provide other services on the same day as AWV but pt deductible/copayment may apply for additional services.
FAQs How do I know if a beneficiary got their AWV through another provider? CMS suggest that providers check with Medicare Administrative Contractor (MAC) to check eligibility (www.cms.gov) HIPAA Eligibility Transaction System (HETS) that you can check a beneficiary s next available date for AWV.
FAQs If a provider completes the AWV and does a comprehensive physical exam even though its not covered by Medicare, can provider elect to not bill the patient for non-covered service? CMS does not require providers to submit claims for non-covered services to the patient at no charge. CMS notes that decision whether or not to charge a patient for non-covered Medicare services is at the discretion of each provider.
FAQs Is an Advanced Beneficiary Notice (ABN) required for non-covered services? Not required. Good practice would be to alert patient to financial liabilities and a voluntary ABN is one way of doing that.
Resources American College of Physicians Acponline.org/practice-resources Family Practice Management Aafp.org/fpm/toolbox
References Medicare.gov CMS.gov Uspreventiveservicestaskforce.org THANK YOU!