Annual Wellness Visits & Preventive Screening Schedule

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Introduction

This summary outlines the key aspects of Annual Wellness Visits (AWVs), particularly focusing on Medicare Annual Wellness Visits (MAWVs), based on the provided source material. It covers their importance, the different types, eligible providers, required components, documentation, handling of concurrent medical issues, and practice models.

Importance and Rationale of Annual Wellness Visits

Annual Wellness Visits are emphasized as a critical component of primary care, focusing on preventive medicine. Providers in primary care, including physicians, physician assistants, nurse practitioners, and internal medicine physicians, are boarded in preventive medicine, making this a core daily activity. Setting aside dedicated time for AWVs allows for a deliberate focus on prevention.

The benefits of AWVs are multi-faceted:

• Patient Engagement: Patients visually perceive that providers care and are dedicating extra time for their visit, fostering a proactive approach to preventive care. This often leads to positive patient satisfaction.
• Improved Patient Health: Focusing on prevention inherently improves patient health.
• Reduced Healthcare Costs: By improving health, AWVs contribute to lowering the overall cost of medicine and patient care.
• Quality Improvement: AWVs serve as an opportune time to close quality gaps. Organizations are documenting this quality care, and health plans are actively reviewing this data.
• Enhanced Revenue and Compensation: Health plans may provide more payment to organizations that demonstrate higher quality of care compared to peers. Appropriately performing and documenting AWVs creates an additional revenue opportunity. For providers within Baylor St. Luke's Medical Group (BSLMG), completing AWVs is part of their wellness quality metric for compensation. Appropriately coding the visits is essential to receive this credit.

Understanding Medicare Annual Wellness Visits

For Medicare patients, the specific term for a covered wellness visit is the Medicare Annual Wellness Visit (MAWV). It is explicitly stated that there is no such thing for Medicare patients as an annual physical, routine physical, or wellness visit outside of this nomenclature. Routine physical exams are not covered by Medicare. MAWVs are distinct from commercial insurance wellness visits and have specific documentation requirements.

Types of Medicare Annual Wellness Visits and Timing

There are three primary types of Medicare wellness visit codes:

1. Welcome to Medicare Visit (Initial Preventive Physical Exam - IPE): This visit must be performed within the first 12 months of the patient's effective date of Medicare Part B coverage. It is covered only once in a lifetime. If a patient does not have this visit within the initial 12-month window, the opportunity to bill for an IPE is lost. An EKG is typically provided at this visit as a baseline.
2. First Annual Wellness Visit: This visit can be billed at least 12 months after the Welcome to Medicare visit. Unlike the IPE, the first AWV does not have a strict time limit beyond that initial 12-month waiting period after the IPE; it can be performed years later if no AWV has been completed before. It is covered only once in a lifetime. An EKG may also be performed at this visit as a baseline.
3. Subsequent Annual Wellness Visits: These are all the visits that occur after the Welcome to Medicare visit and the First Annual Wellness Visit. Subsequent AWVs must be performed at least 11 months after the previous wellness visit. This can be simplified by thinking of it as being done in the same calendar month as the previous year's visit. The previous requirement of waiting 366 days has changed. Subsequent AWVs do not typically include an EKG or a full eye exam, as these are generally one-time benefits.

It is crucial to note that the Medicare wellness portion of these visits has no co-pay or fee for the patient.

Eligible Providers for Medicare Annual Wellness Visits

Medicare Part B covers MAWVs if performed by:

• Physician
• Physician Assistant (PA)
• Nurse Practitioner (NP)
• Clinical Nurse Specialist (RN or LVN)
• Health Educators
• Registered Dietitians
• Nutrition Specialists
• Other licensed practitioners and teams of medical professionals working under the direct supervision of a physician.

Virtual MAWVs can be performed by a physician, nurse practitioner, physician assistant, or RN. However, an LVN cannot perform these visits virtually.

Components and Requirements of a Medicare Annual Wellness Visit

The sources detail numerous components required by CMS to appropriately bill for a Medicare AWV. While seemingly daunting, many elements are part of routine patient care or can be streamlined through documentation tools. Missing a single component can result in not meeting the requirements for billing. Key required components include:

• Review and Update Histories:
  • Patient's medical and social history (past medical/surgical, allergies, current medications, family history). This is a chance to intentionally ensure charts are up to date.
  • Diet, physical activities, social activities, social engagement.
  • Alcohol, tobacco, and drug use.
  • A Health Risk Assessment (HRA) is a standardized questionnaire used to capture many of these history elements and risk factors. It may include questions about Activities of Daily Living (ADLs), fall risk, hearing, advanced directives, lifestyle, safety, pain, social support, and demographic information. Patients can fill this out while waiting. It should also include a list of the patient's health providers and equipment suppliers.
• Mental Health Screening: Review potential depression risk factors. A PHQ2 questionnaire is sufficient for this screening. The PHQ2 is often integrated into the HRA. Documentation in structured data fields in the EHR (like a smart form in ECW or structure data in Epic) is needed for credit.
• Functional Ability and Safety Assessment: Review functional abilities and safety levels. The HRA often includes questions about ADLs and risk of falling. This helps identify needs for assistance and community resources.
• Exam Portion: This is not a traditional comprehensive physical exam. The minimum required elements are:
  • Height, weight, and BMI.
  • Blood pressure check.
  • Visual acuity screening (Snellen chart).
  • Listening to heart and lungs or performing a comprehensive exam (cardiovascular, respiratory, abdominal, etc.) is not required by CMS for billing the AWV code. However, performing these is encouraged for patient reassurance and satisfaction.
• Cognitive Assessment: Screening for cognitive impairment. The Mini Cog is a tool used in some markets, consisting of three words recall and a clock drawing. If a patient fails, further assessment (e.g., MoCA) or referral may be appropriate, or a discussion with the patient should occur. Documenting patient decline is acceptable if they refuse the assessment.
• End-of-Life Planning: Discussing advanced directives, medical power of attorney, and wills is required if the patient agrees. This conversation aims to ensure plans are in place for potential future events and are made without duress. If sufficient time is spent on this, it can be billed separately. Offices may have forms available to facilitate this discussion.
• Opioid and Substance Use Screening:
  • Review current opioid prescriptions and screen for opioid use disorder risk factors. This may involve asking about current opioid use, withdrawal symptoms, pain management providers, and potentially using the Opioid Risk Tool (ORT).
  • Screen for potential substance use disorders, including illegal/recreational drug use and alcohol use. The HRA or structured questions may include items like the CAGE questions.
• Education, Counseling, and Referral: Based on any findings from the assessment and HRA, provide education, counseling, and refer patients to appropriate services in the community or for other preventive services. Identifying gaps in social networks and connecting patients with resources is important.
• Personalized Health Plan and Screening Schedule: A copy of a personalized health plan and screening schedule must be given to the patient and scanned into the chart. This document lists Medicare-covered preventive benefits (e.g., certain vaccines, lab work, screenings like lung cancer screening based on specific Medicare criteria) and indicates when they were last done/ordered, when they are next due, or if the patient declined them. It is important to be aware of Medicare's specific coverage criteria (e.g., age limits for lung cancer screening) and discuss potential costs with the patient if ordering something outside these criteria. The schedule lists services typically given in the office under Medicare Part B, excluding services like Shingrix which is a Part D benefit.

Documentation and EHR Use

Effective documentation is crucial to meet billing requirements and withstand audits.

• Standardized templates or packets are recommended to ensure all required components are covered, as missing even one item can lead to non-compliance. These templates often integrate HRA results, assessment findings, and planned interventions.
• In EHR systems like Epic, there may be a dedicated AWV tab that covers most questions. However, certain key items, such as the status of the patient's advanced directive (e.g., scanned today, patient will bring later) and the Opioid Risk Tool assessment results, must be explicitly documented in the History of Present Illness (HPI) portion of the note for auditing purposes, as they may not be fully captured in the AWV tab.
• In ECW, wellness visit templates help structure documentation and can automatically order related items like EKG (for initial visits), vision screen, and cognitive assessments (like Mini Cog).
• It is generally not necessary to transcribe every single patient answer from the HRA into the EHR note. If the HRA or other supporting documents are scanned into the chart and referenced in the note, and the key required elements are addressed, this can be sufficient for billing.

Handling Additional Medical Issues During an AWV and Billing

Patients attending an AWV may have existing chronic conditions or present with new medical issues. The sources clarify how to handle this:

• If a medically necessary issue arises during an AWV and is evaluated and addressed, it can be charged for in addition to the AWV.
• This is accomplished by billing the appropriate Evaluation and Management (E/M) code (e.g., 99213, 99214) for the time spent or complexity of managing the medical issue.
• A modifier 25 must be added to the E/M code to indicate it was a significant, separately identifiable E/M service performed on the same day as the preventive service. This allows both the AWV G-code and the E/M code to be billed.
• This dual billing is permissible if the provider performing the AWV is a physician or an Advanced Practice Provider (APP) (Physician Assistant or Nurse Practitioner). These providers can bill E/M codes.
• If an RN or pharmacist is conducting the AWV and a medical issue like elevated blood pressure is identified, they cannot bill an E/M code. In such cases, they should inform the patient and the supervising physician/APP and schedule a separate appointment for the patient to be seen by a physician or APP to address the medical issue. If the patient is symptomatic (e.g., headache with high blood pressure), the RN might need to get the physician immediately involved.
• For Medicare patients with whom the provider has a longitudinal relationship, a G2211 code can also be billed in addition to an E/M code (99212-99215), but it cannot be billed with just the wellness visit alone.

Patient Expectations and Communication About Costs

A common patient expectation for a wellness visit is that there will be no co-pay. If an E/M service is added to the AWV to address a medical condition, this may result in a co-pay.

• It is crucial to warn patients upfront that if medical issues are addressed during the visit, there may be an additional charge or co-pay.
• Providing a letter or sheet at check-in that explains the difference between wellness visits and office visits, outlining what is covered and what is not, and stating that addressing other medical issues will incur a co-pay helps manage patient expectations.
• Explain that combining the wellness visit with follow-up for chronic conditions (like diabetes or blood pressure) is done for the patient's convenience, allowing them to address all needs in one visit rather than requiring separate appointments. Patients often understand that they would have a co-pay for a separate chronic care follow-up visit anyway.
• Some practices collect the expected co-pay upfront when scheduling if they know the patient is coming in for a combined visit (e.g., Medicare wellness visit slash diabetes follow-up).

Practice Models for Annual Wellness Visits

Different models can be used to incorporate AWVs into practice.

• One model involves tandem appointments, where an Annual Wellness Visit nurse (like an RN or LVN) spends a significant amount of time with the patient first (e.g., an hour) to complete the AWV components, including histories, HRA, social determinants of health screening, etc. Following this, the physician or APP sees the patient for a shorter visit (e.g., 15-20 minutes) to address any medical issues, manage chronic conditions, refill medications, order referrals, etc.
• This tandem approach provides the patient with more time with the team and is seen as a significant patient satisfier.
• In this model, the nurse completes the AWV documentation, and the provider codes the E/M visit for the chronic/acute medical issues. The provider can also use this opportunity to identify and recapture Hierarchical Condition Categories (HCC) codes.
• Alternatively, a provider (physician or APP) can perform the AWV themselves. In this case, medical assistants can assist with obtaining initial information or completing paperwork/EHR tabs related to the AWV before the provider enters the room. If the provider does the AWV and manages chronic conditions in the same visit, they will add the 25 modifiers to the E/M code.

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