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The Medicare Wellness Exam

The Medicare Wellness Exam. Marc price, do family medicine of Malta, physician owner NYSAFP Treasurer and advocacy chair. Overview. The History behind the Medicare Wellness Exams What are the Medicare Wellness Exams What is covered by the Medicare Wellness Exams

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The Medicare Wellness Exam

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  1. The Medicare Wellness Exam Marc price, do family medicine of Malta, physician owner NYSAFP Treasurer and advocacy chair

  2. Overview • The History behind the Medicare Wellness Exams • What are the Medicare Wellness Exams • What is covered by the Medicare Wellness Exams • How to code for the Medicare Wellness Exams

  3. The History • 3/23/10 - The Patient Protection and Affordable Care Act • Amended 3/30/10 – Health Care And Education Reconciliation Act • Goal • To end some of the worst abuses by the insurance industry and to award Americans new rights and benefits • 4 Year roll implementation

  4. The Medicare Wellness Exams • In the words of CMS: • “CMS is committed to promoting the appropriate use of Medicare preventive services. Medicare now covers a broad range of services to prevent disease, detect disease early when it is most treatable and curable, and manage disease so that complications can be avoided…” • “…CMS recognizes the crucial role that health care providers play in providing and educating Medicare beneficiaries about potentially life-saving preventive and services and screenings.”

  5. What is Covered • Preventive services • Initial Preventive Physical Exam (IPPE) • AKA Welcome to Medicare Preventive Physical • Annual Wellness Visit (AWV) • Screenings • Vaccinations • Behavior therapy and counseling

  6. Welcome to Medicare (IPPE) • Once in a lifetime • Within 12 months of initiation of Medicare Part B coverage • Copay/Coinsurance: • No • Elements • History • Medical and social history • Screening for depression/mood disorders • Functional ability and safety evaluation • Examination • Assessment for end-of-life planning • Counseling and Education • Including a written plan

  7. Annual Wellness Visit (AWV) • Initial visit vs Subsequent visit • Not within 12 months of starting benefits or last IPPE/AWV • Copay/Coinsurance: • No • Elements • History • Same as IPPE • Examination • Same as IPPE, but no mention of end-of-life planning • List of current healthcare providers and suppliers • Counseling and Education • Written screening schedules, interventions and health advice • Referrals to health education or preventive counseling services

  8. IPPE and AWV Clarifications • “Preventive wellness visits” are not annual physical exams • Can be performed by a qualified health professional • Although specific labs/tests are not included in the IPPE or AWV, tests may be ordered resulting from the exam • One-time AAA screening only covered if ordered during an IPPE, not an AWV

  9. IPPE and AWV Clarifications • A diagnosis code is required, but not a specific one • Confirm an IPPE or AWV hasn’t been performed within the past 12 months • Separate E/M and medically necessary services can be billed at the same time as the IPPE or AWV with modifier -25

  10. Screening • EKG • IPPE only • Copay/Coinsurance: Yes • Ultrasound for AAA • IPPE only and if meets certain criteria • Copay/Coinsurance: No • Cardiovascular Screening - Lipids • Every 5 years • Copay/Coinsurance: No

  11. Screening • Diabetes – fasting/non-fasting glucose/GTT • Non-diabetics meeting criteria • 1-2 times per year depending on previous results • Copay/Coinsurance: No • Glaucoma • Annually if criteria met • Copay/Coinsurance: Yes • Bone Mass Measurement • Every 2 years if criteria met (sooner if medically necessary) • Copay/Coinsurance: No

  12. Screening • Colorectal Cancer – several options • Age > 50 yo, timing varies depending on test and risk factors • Copay/Coinsurance: No • Prostate – DRE/PSA • Annually beginning the day after 50th birthday • Copay/Coinsurance: PSA – No/ DRE – Yes • Depression • Annually • Copay/Coinsurance: No

  13. Screening • Pap Tests • Annually if certain criteria met, otherwise every 2 years • Copay/Coinsurance: No • Pelvic Exams • Annually if certain criteria met, otherwise every 2 years • Copay/Coinsurance: No • Mammography • Female 35-39 yo - one baseline, >40 yo – annually • Copay/Coinsurance: No

  14. Screening • Alcohol Misuse • Annual screening • Copay/Coinsurance: No • Sexually Transmitted Infections • Women – GC/Chlamydia/Syphilis/Hepatitis B • Annually for increased risk, 1-3 times per pregnancy (dzdependant) • Men – Syphilis only • Annually for increased risk • Copay/Coinsurance: No • HIV • Annually for high risk patients, 3 times per pregnancy • Copay/Coinsurance: No

  15. Vaccinations • Seasonal Influenza • Once per season, more if medically necessary • Copay/Coinsurance: No • Pneumonia • Once in a lifetime, more if medically necessary and > 5 yrs since last • Copay/Coinsurance: No • Hepatitis B • Scheduled dosing if at high or intermediate risk • Copay/Coinsurance: No

  16. Vaccinations • Those NOT covered under Medicare Part B • Zoster Vaccine • TDaP • Though covered under Medicare Part D (medications)

  17. Counseling • Diabetes Self-Management Training • Individual or group; 10 hrs 1st year, 2 hrs subsequent years • Copay/Coinsurance: Yes • Medical Nutrition Therapy • Individual or group; 3 hrs 1st year, 2 hrs subsequent years • Diabetes, renal disease/kidney transplant within 3 yrs • Copay/Coinsurance: No • Intensive Behavioral Therapy for CV Disease • Individual; Annually • Copay/Coinsurance: No

  18. Counseling • Intensive Behavioral Therapy for Obesity • Individual; Multiple visits over 6-12 months • Copay/Coinsurance: No • Tobacco Use • Two cessation attempts per year; up to 4 sessions per attempt • Copay/Coinsurance: No • Alcohol Misuse (Not Dependence) • Individual; Four visits per year • Copay/Coinsurance: No • Sexually Transmitted Infection Prevention • Individual; Twice per year • Copay/Coinsurance: No

  19. How To Code

  20. How To Code

  21. How To Code

  22. How To Code

  23. How To Code

  24. How To Code

  25. How To Code

  26. Resources • http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo • http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf • http://www.medicare.gov/coverage/preventive-and-screening-services.html • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html

  27. Questions? • Contact Information • Marc Price, D.O. • 2388 Route 9, Suite 200, Mechanicville, N.Y. 12118 • 518-899-5390 • drprice@nycap.rr.com • Twitter: Bald_and_Proud

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