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The Medicare Annual Wellness Visit- It’s Origin, Content, and Substance. Duke Internal Medicine Bruce Peyser, MD FACP, Scott Joy, MD FACP, Anne Phelps, MD, Kathleen Waite, MD FACP May 2012. Disclosures for all four physicians. Disclaimer.

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the medicare annual wellness visit it s origin content and substance

The Medicare Annual Wellness Visit-It’s Origin, Content, and Substance

Duke Internal Medicine

Bruce Peyser, MD FACP, Scott Joy, MD FACP, Anne Phelps, MD, Kathleen Waite, MD FACP

May 2012


Comments are from us as individuals and do not represent official recommendations from Duke University Medical Center.

However, we are from the Department of Medicine at Duke.

And most importantly, we are all

BLUE DEVILS and we sure love basketball in Durham, NC.

awv pitfalls what to watch out for
AWV Pitfalls-What to Watch out for??

Insufficient or incomplete documentation.

Many rules and regulations, CMS does not have all the answers yet.

Concurrent provision of E/M services seems like an easy way to get into trouble.

These visits take time, and your staff need to help you.

Its not really clear what records you must retain .

How to do this with EPIC??

common questions and course objectives
Common Questions and Course Objectives

What to do when

A test is abnormal?

How did the AWV

get developed?

What are the

Components of the


What’s a HRA?

What are common

Errors made with


How to Bill for the AWV?

How to teach learners

To do this properly?

today s outline we have a really great show
Today’s outline-We have a really great show!

AWV-Background and Politics- Dr. Scott Joy

Component overview w/ focus on HRA- Dr. Kathleen Waite

What to do when an abnormality is discovered-Dr. Anne Phelps

Billing 101-How to bill correctly-Dr. Bruce Peyser

Question and Answers

Session Evaluation

the magic of the awv
The Magic of the AWV

Be prepared for surprises!

It’s hard to anticipate what you will find.

This is an incredible opportunity that we must not squander.

the political history of the affordable care act and the annual wellness visit

The Political History of the Affordable Care Act and the Annual Wellness Visit

Scott V. Joy, MD, FACP

Associate Professor of Medicine

Duke Primary Care

presidential power
Presidential Power
  • President Obama said that fixing health care would be one of his priorities if he won the presidency
  • President Obama announced to a joint session of Congress in February 2009 that he would begin working with Congress to construct a plan for health care reform.
committees of importance u s senate
Committees of Importance:U. S. Senate
  • Finance
    • Chairman, Max Baucus, D-MT
    • Ranking Member, Orin Hatch, R-UT
  • HELP (Health, Education, Labor and Pensions)
    • Chairman, Tom Harkin, D-IA
    • Ranking Member, Michael Enzi, R-WY
  • Appropriations
    • Chairman, Daniel Inouye, D-HI
    • Ranking Member, Thad Cochran, R-MS
genesis of the awv
Genesis of the AWV

*Senators Max Baucus (D-Montana), Chuck Grassley (R-Iowa),

Kent Conrad (D-North Dakota), Olympia Snowe (R-Maine),

Jeff Bingaman (D-New Mexico), and Mike Enzi (R-Wyoming

  • Beginning June 17, 2009, and extending through September 14, 2009, three Democratic and three Republican Senate Finance Committee Members* met for a series of 31 meetings over 60 hours to discuss the development of a health care reform bill
  • The principles that they discussed became the foundation of the Senate's health care reform bill.
committees of importance house of representatives
Committees of Importance:House of Representatives
  • Ways and Means

Chairman, Dave Camp, R-MI

Ranking Member, Sander Levin, D-MI

  • Appropriations

Chairman, Harold Rogers, R-KY

Ranking Member Norman D. Dicks, D-WA

  • Energy and Commerce

Chairman, Fred Upton, R-MI

Henry Waxman, D-CA

the legislative history of the affordable care act
The Legislative History of the Affordable Care Act

  • Introduced in the House asthe "Service Members Home Ownership Tax Act of 2009" (H.R. 3590) by Charles Rangel (D–NY) on September 17, 2009
  • Committee consideration by: Ways and Means
  • Passed the House on October 8, 2009 (416–0)
  • Passed the Senate as the "Patient Protection and Affordable Care Act" on December 24, 2009 (60–39)
    • “Cornhusker Kickback”
    • January 19, 2010, Scott Brown elected Senator from MA
understand the game how our laws are made1
Understand The Game: How Our Laws Are Made

House agreed to Senate amendment on March 21, 2010 (219–212)


WASHINGTON, March 23, 2010 - President Obama signed the health care bill into law today, calling its historic expansion of insurance coverage "reforms that generations of Americans have fought for and marched for and hungered to see.”

the implementation phase
The Implementation Phase
  • Once the ACA was passed, it became the responsibility of CMS (under Department of Health and Human Services, Secretary Kathleen Sebelius, to create policies
  • Each year, CMS issues regulations in the Federal Register
  • Generally the Proposed Rule comes out in the summer for a 90 day comment period and then the Final Rule is issued, effective January 1, 20XX
u s alters rule on paying for end of life planning
U.S. Alters Rule on Paying for End-of-Life Planning

Published: January 4, 2011

  • WASHINGTON — The Obama administration, reversing course, will revise a Medicare regulation to delete references to end-of-life planning as part of the annual physical examinations covered under the new health care law, administration officials said Tuesday.
  • The move is an abrupt shift, coming just days after the new policy took effect on Jan. 1.
supreme court and aca
Supreme Court and ACA

  • The Supreme Court has granted review of four issues from challenges to the Affordable Care Act that have been pursued in the federal courts since passage of the act in March 2010.
  • The four issues on which the court has granted review are:
    • Whether the Anti-Injunction Act prevents challenges to the Affordable Care Act at this time
    • The constitutionality of the individual mandate, requiring most Americans to purchase health insurance by 2014
    • Whether the individual mandate is severable if it is found to be unconstitutional, or whether the entire Act would have to fail
    • Whether the Affordable Care Act's expansion of the Medicaid program is constitutional
supreme court and aca1
Supreme Court and ACA

  • The Affordable Care Act does not contain a severability clause.
  • Severability clauses provide that the failure of one provision in an act of Congress does not affect the remaining portions of the act.
  • The absence of a severability clause does not mean that provisions are not severable, but it can leave the decision regarding severability up to the courts.
public opinion of aca
Public Opinion of ACA

medicare s annual wellness visit the benefit nobody knows
Medicare’s Annual Wellness Visit: The benefit nobody knows

John A. Hartford Foundation Public Poll: “How Does It Feel? The Older Adult Health Care Experience”

*Medicare’s records suggest that uptake is only 6.5 percent

components of medicare annual wellness visit awv

Components of Medicare Annual Wellness Visit (AWV)

Kathleen Waite, MD, FACP

Assistant Clinical Professor of Medicine

Division of General Internal Medicine

Duke Primary Care

medicare preventive services

Medicare Preventive Services

Initial Preventive Physical Examination (IPPE)

One time benefit

Must be provided within the first 12 months of the patient’s Medicare Part B coverage

Initial Annual Wellness Visit (AWV)

Once in a lifetime benefit

If patient has received an IPPE then need to wait a full 12 months from that date of the IPPE before performing an AWV

Subsequent Annual Wellness Visit (AWV)

Provided yearly

Must scheduled at least 11 full months from the last AWV

goals of the awv

Goals of the AWV

Patient to review with their health care provider overall health status and maximize the preventive services that are available to Medicare beneficiaries.

Components dictated by Medicare.

Create a personalized prevention plan.

It is NOT a physical exam.

components of first awv

Components of First AWV

Establish Medical History

Past medical and surgical history


Medication list INCLUDING supplements

Establish Family History

Includes parents, siblings and children

List of current medical providers/suppliers

Depression screening

Review current and past experience with mood disorders.

If no history then screen with available “standard screening test” recognized by national professional medical organizations. (PHQ-2)

components of first awv1

Components of First AWV

Review patients functional ability and level of safety

Hearing (Whisper test)

Ability to perform ADLs (Consider Katz or other instrument)

Fall Risk (Get up and go test)

Home safety

Include instrumental activities of daily living (iADLs)


Height, Weight, BMI or waist circumference, BP

Other PE deemed appropriate per medical/family history

Detection of any cognitive impairments

Not specified – consider testing such as Mini Cog

Health Risk Assessment (CHANGE for 2012)

health risk assessment hra

Health Risk Assessment (HRA)

Center for Medicare and Medicaid Services (CMS) requires that a HRA be completed as part of the Medicare AWV effective Jan. 1, 2012. CMS does not require a specific HRA.

Written at a 5th grade reading level.

Should take no more than 20 min to complete.

Can be complete before or during the AWV.

Can be web based, telephonic or paper based.

cdc guidance on hra

CDC Guidance on HRA

Demographic information

Self assessment of health and physical functioning

Biometric Assessments

Height, weight, BP, lipids, glucose

Psychosocial risks

Depression, social isolation, pain, stress/anger

Behavioral risks

Physical activity, nutrition, sexual practices, home safety, motor vehicle safety, tobacco use, alcohol use.

ADLs and Instrumental activities of daily living (iADLs)

hra resources

HRA Resources

Center for Disease Control and Prevention published online a “Framework for Patient-Centered Health Risk Assessment”. Appendix A contains a 7 page paper HRA.

Dartmouth Co-Op Project is a non-profit organization that has an online free HRA. Short and long online HRA. The short HRA takes approximately 10 min to complete. Patient is given a summary “Action and Planning Form” which they are asked to print and bring to the AWV.

sample hra printout

Sample HRA Printout


awv counseling requirement

AWV Counseling Requirement

Establishment of written screening schedule for patient for the next 5 to 10 years.

Based on United States Preventive Services Task Force (USPSTF) grade A and B recommendations.

Based on Advisory Committee on Immunization Practices (ACIP)

Example check list available (electronic form available to patients)


awv counseling requirement1

AWV Counseling Requirement

List risk factors and conditions which interventions are recommended.

Examples sedentary lifestyle, fall risk, tobacco use

Provide personalized health advice and referrals for health education and preventive counseling.


uspstf grade a and b recommendations
USPSTF Grade A and B Recommendations


  • AAA Screening (B)

Men 65-75 with tobacco history

  • ASA

Men 45-79 (A),Women 55-79 (B)

  • Blood Pressure (A)
  • Cholesterol Screen (A)

Men > 35, Women > 45

  • Diabetes screening (B)

If BP persistently over 135/80

  • Dietary Counseling (B)

If hyperlipidemia, or other CV risk

Health Habits

  • Alcohol Misuse (B)
  • Depression Screen (B)
  • Obesity Screen (B)
  • Sexually Transmitted Infection Counseling (B), HIV (A) ,GC (B), Syphilis(B)
  • Tobacco Use Counseling (A)
uspstf grade a and b recommendations1
USPSTF Grade A and B Recommendations

Osteoporosis Screening

  • Bone density

All women 65 and older.

Cancer Screening

  • Breast
    • BRCA counseling high risk family history (B)
    • Chemoprevention (B)
    • Mammogram (B)
  • Cervical (A)
  • Colon (A)

preventive services covered by medicare

Preventive Services Covered by Medicare

Immunizations: Flu, Hepatitis B, Pneumovax

Cancer Screening: Colon, Pelvic Exam and Pap Smear, Prostate, Mammogram

Bone Density Testing (every 2 years)

Cardiovascular Screening (lipids every 5 years)

Diabetes Screening (depends on risk factors)

AAA Screening/EKG (once – only with IPPE)

Glaucoma testing

STI and HIV Screening

Alcohol Misuse Counseling and Tobacco Cessation

comparison between uspstf recommendations and medicare coverage

Comparison Between USPSTF Recommendations and Medicare Coverage

Disparity between current USPSTF guidelines and preventive services covered by Medicare.

USPSTF recommended against (D-rated) some preventive services yet Medicare reimburses physicians for these. Example, prostate cancer.

AWV uses USPSTF guidelines and ACIP guidelines.

Lesser, Lenard et al, Ann Fam Med 2011; Vol 9, No 1, pg 44-49

subsequent awvs

Subsequent AWVs


Updated medical and family history

Update list of current providers and suppliers

Physical Exam (BP, Height, Weight, BMI or waist circumference)

Update written screening schedule and list of risk factors and medical conditions which require interventions

Provide personalized health advice and referrals for health education and preventive counseling

subsequent awvs1

Subsequent AWVs

What is Different from Initial AWV?

Depression Screen – Unique to Initial AWV but still addressed in the HRA.

Functional Ability – hearing, ability to perform ADLs, fall risk, home safety. Unique to Initial AWV but still addressed in the HRA.

advance planning

Advance Planning

NOT required for either the initial or subsequent AWV.

Optional to discuss and include during visit.

annual wellness visit screening tests

Annual Wellness Visit Screening Tests

Anne Phelps, MD

Assistant Professor of Medicine

Duke University Medical Center

depression screen patient health questionnaire phq2

Depression ScreenPatient Health Questionnaire PHQ2

Over the last 2 weeks, how often have you been bothered by any of the following symptoms?



The PHQ2 is scored from 0-6.

A score > 3 had a sensitivity of 83% and a specificity of 92% for major depression.

Higher scores correlate with:

A decrease in functional status

An increase in symptom-related difficulty

Sick days from work

Source: Medicare 2003 Nov;41(11):1284-92.

depression screen

Depression Screen

If your PHQ2 is positive with a score greater than 3 you could consider screening the patient with a PHQ9.

The PHQ9 is a set of nine questions scored the same way as the PHQ2.

The PHQ9 gives guidance on treatment and therapy options.

depression screen1

Depression Screen

Over the last 2 weeks how often have you been bothered by any of the following symptoms?

Little interest or pleasure in doing things?

Feeling down, depressed, or hopeless?

Trouble falling or staying asleep, or sleeping too much?

Feeling tired or having little energy?

Poor appetite or overeating?

Feeling bad about yourself or that you are a failure or have let yourself or your family down?

Trouble concentrating on things, such as reading the newspaper or watching television?

Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual?

Thoughts that you would be better off dead or of hurting yourself in some way?

scoring the phq9

Scoring the PHQ9

From Kroenke K, Spitzer RL, Psychiatric Annals 2002;32:509-521

phq9 sensitivity and specificity

PHQ9 Sensitivity and Specificity

The PHQ9 has a sensitivity of 0.77 (0.71-0.84).

The PHQ9 has a specificity of 0.94 (0.90-0.97).

This was in an unselected group of primary care patients. Gen Hosp Psychiatry 2007 Sep-Oct;29(5):388-95.


Pfizer website to download the PHQ9.


Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute

hearing test whispered voice test

Hearing TestWhispered Voice Test

Stand one arm’s length behind the patient.

Occlude the opposite ear

Exhale before speaking.

Whisper a combination of 3 numbers and letters (4, S, K).

If the patient responds incorrectly, then repeat using a different number letter combination.

Test each ear separately.

whispered voice test

Whispered Voice Test

The test is normal if the patient repeats at least 3 of a possible 6 numbers or letters correctly.

The sensitivity is 90% and the specificity is 70-87% for this test.

If the test is abnormal, refer to audiology for formal hearing testing and hearing aid evaluation.

Sandi Pirozzo, Tracey Papinczak, Paul Glasziou, BMJ. 2003 October 25; 327(7421): 967. 10.1136/bmj.327.7421.967

mobility and fall screening tool timed get up and go test

On the word “Go” time the patient to do the following:

Mobility and Fall Screening ToolTimed Get Up and Go Test

Stand up from the chair

Walk 3 meters in a line

Turn around

Walk back to the chair

Sit down

Normal result: < 10 seconds

Abnormal result: >20 seconds

timed get up and go test

Score: Balance function was scored on a five-point scale:

Timed Get Up and Go Test

1 = normal;

2 = very slightly abnormal;

3 = mildly abnormal;

4 = moderately abnormal;

5 = severely abnormal.

Patients with score of 3+ are at risk for falling.

Mathias, S., Nayak, U.S.L., & Isaacs, B. (1986). Balance in the elderly patients: The "get-up and go" test. Archives of Physical Medicine and Rehabilitation, 67(6), 387-389.

treatment for abnormal results

Treatment for abnormal results?

Refer to physical therapy for gait training, which focuses on balance and resistance training.

Consider OT evaluation for mobility devices and walkers.

Suggest Calcium and Vitamin D supplementation.

Screen for osteoporosis.

Falls risk prevention:

falls risk prevention

Falls Risk Prevention

Remove rugs and small objects

Increase lighting

Add grab bars and handrails

Evaluate medications:


Antidepressants and neuroleptic agents

Hypertension medications

Avoid physical restraints

Avoid immobility

memory test the mini cog

Memory Test:The Mini Cog

Ask your patient to remember 3 unrelated words and repeat them back to you.

Ask your patient to draw the face of a clock on a sheet of paper with a clock circle already drawn on the page.

After they have drawn the clock face, ask them to draw a specific time like 10:10.

Ask the patient to repeat the three stated words.


Borson S. The mini-cog: a cognitive “vitals signs” measure for dementia screening in multi-lingual elderly Int J Geriatr Psychiatry 2000; 15(11):1021.
what can we do with abnormal mini cog results

What can we do with abnormal Mini Cog results?

Evaluate the degree of dementia Folstein Mini Mental Status Exam (MMSE)

Evaluate for cerebral vascular disease, delirium, or depression which can mimic dementia.

Evaluate for metabolic causes like B12, thyroid, folate, iron or copper abnormalities.

katz index of adl

Katz Index of ADL

Katz, S., Down, T.D., Cash, H.R., & Grotz, R.C. (1970) Progress in the development of the index of ADL. The Gerontologist, 10(1), 20-30.

billing 101 how to bill correctly and stay out of trouble
Billing 101: How to Bill Correctly (and Stay out of trouble!)

Bruce Peyser, MD FACP

Associate Professor of Medicine

Duke University Medical Center

billing issues and guidelines
Billing Issues and Guidelines

Billing for AWV’s can be straight forward, or complex, depending on what you do.

Will review the guidelines.

Will talk about how to do this correctly.

who can bill for the awv
Who can bill for the AWV?



Physician Assistant

Nurse Practitioner

Clinical Nurse Specialist

Medical Professional Team (can include a health educator, a registered dietitian, nutrition professional, or other licensed practitioner) working under the DIRECT supervision of a physician.

NOT medical assistants, certified nurses aides or certified nursing assistants.

when can you do the annual wellness exam
When Can You do the Annual Wellness Exam?

Mr. Smith enrolls in Medicare on Jan 1, 2012.

Eligible for a Welcome to Medicare visit Jan 1 2012-Dec 31, 2012.

Schedules and gets his visit May 1, 2012.

Eligible for 1st Medicare Annual Wellness visit May 2, 2013.

Eligible for next Medicare Annual Wellness visit April 3, 2014.

does the awv have to take place in a physician s office
Does the AWV have to take place in a physician’s office?

NO it does not.

If service is provided, the following institutions and/or sites can bill for it:


Skilled nursing facilities

Rural health centers

Federally qualified health centers

Critical Access Hospitals

from a practical viewpoint when should one do an awv
From a practical viewpoint, when should one do an AWV??

Once a year.

Plan it/schedule it in advance.

Block out enough time!

Do this when the patient’s health status is stable.

Encourage patient to do HRA prior to visit.

NOT when you are behind, pt needs to use bathroom, has long list of questions, and new problems.

coding for the annual wellness visit
Coding for the Annual Wellness Visit

G0438- AWV with personalized prevention plan service (PPPS), first visit.

G0439-AWV w/ PPPS, subsequent visit

picking the icd 9 10 code for the visit
Picking the ICD-9/10 code for the visit.

A Diagnosis code must be reported on the claim, but no specific single ICD-9 code is required for the AWV.

Could use V70.0, V70.8, or V70.9.

“Any other valid, appropriate diagnosis code would be acceptable.”

-Thomas Dorsey at CMS, from March 28, 2012 National Provider Call

coinsurance deductible and cost sharing
Coinsurance, deductible, and cost sharing..

Copayment or coinsurance, and the Medicare Part B deductible are waived for the AWV.

Cost sharing will apply to the E/M service IF this is provided also.

the awv is a preventative visit it is not a routine annual physical exam
The AWV is a Preventative Visit-It is NOT a Routine Annual Physical Exam

The AWV is NOT intended to be a head to toe physical exam!!!!

Medicare does not cover “complete annual exams”.

Be wary about trying to cover too much , in too short a time period, with inadequate documentation.

To both physicians and patients, this can be very disappointing.

can one bill for other services at the same time as the medicare annual wellness visit
Can one bill for other services at thesame time as the Medicare Annual Wellness Visit?

YES, ONE CAN!!!!!!!

What can be done??

Medically necessary diagnostic ECG. (93000)

Prostate Exam. (G0102)

Breast and Pelvic exam (G0101)

Screening pap smear (Q0091).

“Medically necessary”

E/M services-(Be really really, really careful!!!!!!!)

adding e m services to the awv be careful
Adding E/M services to the AWV-be careful!

Medicare allows for payment of “Medically Necessary” E/M services that are furnished at same visit as AWV.

When these are appropriate, add Modifier 25 and use CPT code range from 99201-99215.

Again cost sharing will apply to the E/M service.

non covered preventative services
Non Covered Preventative Services

Medicare non-covered preventative services may also be billed with an AWV.

Provider must issue an advance beneficiary notice (ABN) to notify the patient that payment for the additional preventative service will fall to the beneficiary.

how to teach learners colleagues residents how to carry out the awv
How to teach learners/colleagues/residents how to carry out the AWV??

Present at a meeting or dinner.

Demonstrate 1:1.

Have templates readily available especially with EPIC users.

Have any of you tried to teach this?

How did that work out?

final common misconceptions
Final Common Misconceptions

The AWV covers a yearly complete head to toe annual exam.

You can do the AWV in a brief period of time.

It’s ok to do the AWV when there are lots of other medical problems that are occurring.

Information within the AWV can be used to support the level of care determination for E/M service.

important links
Important Links

Overview from CMS:

Overview from ACP

Overview from AMA

Overview from Duke

important links1
Important Links

ABC’s of providing the annual Wellness Visit

Annual Wellness Visit

Health Risk Assessment (paper version from Dartmouth)

Health Risk Assessment (electronic version, from Dartmouth)

in summary
In summary…

The Medicare Annual Visit is a relatively new service that we can and should be providing to Medicare beneficiaries.

There is a proper time and place to do this.

You can get help-consider this a team approach.

Make sure your documentation is meticulous, especially if you add E/M codes as well.

Use this time to cover topics that you might not otherwise address.