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The Medicare Wellness Exam

The Medicare Wellness Exam

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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