Last Updated: Aug 11, 2016
The Centers for Medicare and Medicaid Services (CMS) approved wellness visits as a covered benefit beginning Jan. 1, 2011. The Initial Preventive Physical Exam (IPPE) — also known as the "Welcome to Medicare" visit — and the Annual Wellness Visit (AWV) aim to promote wellness among Medicare beneficiaries by preventing or slowing the onset and progression of disease.
PAMED's Annual Wellness Visit Toolkit is a comprehensive resource that can help physicians and practices in carrying out wellness visits and meeting documentation requirements.
CMS' 2013 billing data shows that nationwide, only 12 percent of Medicare fee-for-service (FFS) beneficiaries received their AWV benefit, however. In Pennsylvania, even fewer — only 9 percent — received their AWV. This could mean that practices are leaving money on the table.
WHAT'S AN AWV WORTH?
The components of a wellness visit include medical history, health risk screenings, education, counseling, and referrals. Many of these components are already part of the care coordination physicians provide. Placing greater emphasis on wellness and population health, CMS recognizes the work physicians do in helping their patients get and stay healthy.
Unfortunately, physicians are seeing declining reimbursements because:
- The enhanced Medicaid payments practices received in 2013 and 2014 as a result of an Affordable Care Act (ACA) mandate requiring parity with Medicare payments have expired.
- The 10 percent increase in the Primary Care Incentive Payments ended Dec. 31, 2015.
How many millions of dollars are being left on the table? Reimbursements for wellness visits are significant. They run from $124 to $183 in the Philadelphia area, and $112 to $167 in the rest of Pennsylvania. Compared to 99213 reimbursements ($77.99 and $70.85, respectively), wellness visits can reimburse more than 200 percent of an expanded, problem-focused E/M.
Depending on the area, adding only two wellness visits per day, five days a week, for 45 weeks a year can add $50,000 to $75,000 in gross revenue annually. This is an opportunity for physicians to be reimbursed for the care and services they already provide to their patients.
BUILDING AWV DELIVERY: SEVEN STRATEGIES FOR IMPLEMENTATION
Physicians may be facing gaps in their budgets for any number of reasons. Billing IPPEs and AWVs could help ease those financial challenges. For physicians who are considering adding IPPEs and AWVs, here are seven helpful strategies for implementing this change in your practice:
1. Put together a project plan with a target start date and a budget. Identify and address the unique needs of your practice. Think about, and plan for, the number of visits you will do in a day, week, month, or year.
2. Communicate and engage your staff to understand the actions and goal. Staff can feel threatened by change and may have concerns about how this affects their jobs. If they feel that expanding AWVs is harmful to the practice or their roles, they will resist the move. Engage your staff and encourage them to take ownership of the process. Plan and create short-term wins.
3. Communicate the benefit to patients. Patients have grown accustomed to a problem-based visit that centers around specific medical issues. Help them understand the purpose of the wellness visit, so that they have the appropriate expectations. They should understand that they are not coming in to discuss a medical problem.
Consider preparing a letter explaining your practice's transition to wellness visits and offer it at check-in or checkout, and encourage your patients to schedule. In the event they have a medical problem that needs to be addressed, you can bill a wellness visit and E/M visit together — just be sure to use a 25 modifier. (A word of caution: The history and exam portion of the E/M may have also been part of the wellness visit, and should not be used to determine the level of E/M visit.)
4. Make sure to build the time into your schedule. When you start scheduling patients, you'll need a place to put them. Practices that successfully incorporate wellness visits usually begin the visit with clinical staff performing patient intake and history, and the physician seeing the patient at the very end. Those practices estimate the time required at roughly 20 minutes of staff time and 10 minutes of provider time.
Regrettably, the most frequently cited reason for not billing wellness visits is the interruption to workflow. To effectively add them to your workflows, break down the tasks involved. Delineate the responsibilities associated with each task, and assign them to the appropriate people. Consider using a flow chart to define the responsibilities, then look for ways to increase efficiencies. Could you provide patient forms during checkout of a regular medical visit? How are you going to gather patient histories — through a telephone interview, or a chart review and visit preparation? Look at each task and define where it fits into the flow of your practice to maximize efficiency.
5. Create checklists or templates for documentation. Whether you use paper notes or EMRs, templates will help ensure you don't miss any elements of the visit, and prevent the loss of money in the event of an audit. Have patient forms handy.
6. Check patient eligibility. Most importantly, you need to be sure which benefit the patient is eligible for — the IPPE or AWV. Is this an initial visit, a follow-up, or did the patient use a "free screenings" service? You can use your billing software or clearinghouse to check eligibility. If neither of those is an option, you can create a login for Novitasphere with Novitas Solutions (www.novitas-solutions.com) to check eligibility. You've made the preparations; don't skip this step and risk going unpaid for services provided.
7. Keep your patient on a wellness schedule. Ensure that your patient is returning to your practice for their AWV.
Screening companies inside Pennsylvania and elsewhere are profiting from wellness visits. They conduct isolated screenings advertised as "free" (meaning no cost sharing) to Medicare beneficiaries — your patients — without having established relationships with those patients. Pennsylvania physicians have been building patient relationships and coordinating care for years without reimbursement.
PAMED recognizes the importance of the physician-patient relationship, in addition to the difficulties physicians face: rising costs, declining reimbursements, and rigorous demands from payers and patients. On behalf of members, PAMED approached CMS for comment on the legitimacy of mobile screening businesses, and while they wouldn't say whether CMS would intervene, said, "It is very important
that the [physician] impress upon their patients that the best approach is for the [physician] to order these tests so that the beneficiary can participate in their own care."
Francis Solano Jr., MD, co-authored a resolution adopted by PAMED's House of Delegates in October that directs the society to work with the American Medical Association (AMA) to define who can provide AWVs. It further calls for AWVs to be defined as provided by community-based physicians who are available and will provide continuity of care.
"Who is the most logical and important provider who can direct patients to a healthier lifestyle and focus on preventive care other than their primary care physician?" he asked rhetorically. "It makes no sense for me to allow companies that are purely mercenary in nature to provide the Annual Wellness Visit.
"I don't work for CMS, but feel very strongly that CMS intended this to be a unique opportunity for patients to discuss with their primary care physicians opportunities to provide advice on wellness and preventive care. I'm not sure anyone other than a primary care physician would have a longitudinal relationship with the patient, as well as the data on chronic diseases and how they impact wellness, knowledge of wellness strategies in terms of lifestyle choices, preventive care, and immunizations to present a plan to a patient."