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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.
Duke Internal Medicine
Bruce Peyser, MD FACP, Scott Joy, MD FACP, Anne Phelps, MD, Kathleen Waite, MD FACP
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.
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??
What to do when
A test is abnormal?
How did the AWV
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?
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
Be prepared for surprises!
It’s hard to anticipate what you will find.
This is an incredible opportunity that we must not squander.
Scott V. Joy, MD, FACP
Associate Professor of Medicine
Duke Primary Care
*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
Chairman, Dave Camp, R-MI
Ranking Member, Sander Levin, D-MI
Chairman, Harold Rogers, R-KY
Ranking Member Norman D. Dicks, D-WA
Chairman, Fred Upton, R-MI
Henry Waxman, D-CA
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.”
Published: January 4, 2011
John A. Hartford Foundation Public Poll: “How Does It Feel? The Older Adult Health Care Experience” http://www.jhartfound.org/learning-center/hartford-poll-2012/
*Medicare’s records suggest that uptake is only 6.5 percent
Kathleen Waite, MD, FACP
Assistant Clinical Professor of Medicine
Division of General Internal Medicine
Duke Primary Care
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)
Must scheduled at least 11 full months from the last 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.
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
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)
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)
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)
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.
Self assessment of health and physical functioning
Height, weight, BP, lipids, glucose
Depression, social isolation, pain, stress/anger
Physical activity, nutrition, sexual practices, home safety, motor vehicle safety, tobacco use, alcohol use.
ADLs and Instrumental activities of daily living (iADLs)
Center for Disease Control and Prevention published online a “Framework for Patient-Centered Health Risk Assessment”. Appendix A contains a 7 page paper HRA. http://www.cdc.gov/policy/opth/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. www.medicarehealthassess.orgwww.HowsYourHealth.org
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 http://www.medicare.gov/navigation/manage-your-health/preventive-services/preventive-service-overview.aspx
https://mymedicare.gov/ (electronic form available to patients)
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.
Men 65-75 with tobacco history
Men 45-79 (A),Women 55-79 (B)
Men > 35, Women > 45
If BP persistently over 135/80
If hyperlipidemia, or other CV risk
All women 65 and older.
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)
STI and HIV Screening
Alcohol Misuse Counseling and Tobacco Cessation
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
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
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.
NOT required for either the initial or subsequent AWV.
Optional to discuss and include during visit.
Anne Phelps, MD
Assistant Professor of Medicine
Duke University Medical Center
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.
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.
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?
From Kroenke K, Spitzer RL, Psychiatric Annals 2002;32:509-521
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
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.
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
Stand up from the chair
Walk 3 meters in a line
Walk back to the chair
Normal result: < 10 seconds
Abnormal result: >20 seconds
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.
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:
Remove rugs and small objects
Add grab bars and handrails
Antidepressants and neuroleptic agents
Avoid physical restraints
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.
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, 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.
Bruce Peyser, MD FACP
Associate Professor of Medicine
Duke University Medical Center
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.
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.
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.
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
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.
G0438- AWV with personalized prevention plan service (PPPS), first visit.
G0439-AWV w/ PPPS, subsequent 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
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 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.
YES, ONE CAN!!!!!!!
What can be done??
Medically necessary diagnostic ECG. (93000)
Prostate Exam. (G0102)
Breast and Pelvic exam (G0101)
Screening pap smear (Q0091).
E/M services-(Be really really, really 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.
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.
Present at a meeting or dinner.
Have templates readily available especially with EPIC users.
Have any of you tried to teach this?
How did that work out?
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.
Overview from CMS:
Overview from ACP
Overview from AMA
Overview from Duke
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)
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.