When it comes to providing and being paid for Medicare services, there is often a lot of red tape to cut through. Our guide to the Medicare annual wellness visit, or AWV, sorts through the confusion so that your practice can streamline the process, keeping the focus on delivering excellent patient care. We share tools and best practices to help you conduct these visits efficiently while ensuring that they also make good financial sense for your practice.
Preventive medicine has the potential to save lives. According to the Centers for Disease Control and Prevention, if everyone in the United States received recommended clinical preventive care, more than 100,000 lives could be saved each year.”
Though it’s widely recognized that preventive care contributes positively to overall wellness, many challenges exist when it comes to implementing a Medicare preventive screening program in a traditional medical practice. The intention of Medicare in providing the annual wellness visit is commendable; however, the confusion surrounding what this visit is — and what it is not — complicates matters.
In some cases, misinformation and complex requirements lead to patients failing to take advantage of the covered service, thus missing out on the health benefits while practices consequently forfeit revenue opportunities. In other instances, medical professionals may be reluctant to conduct the Medicare annual wellness visit, deeming the potential hassles and convoluted billing process not worth their effort. On top of these, you can add ever-evolving guidelines and coding requirements. In either scenario, the result is the same: missed opportunities for enhanced patient care and revenue that is left on the table.
Even if you are currently performing Medicare annual wellness visits, your healthcare practice may be using unnecessary, inefficient resources to complete the reporting and billing process for these visits or even missing out on revenue for services performed altogether. In fact, a medical practice can be reimbursed initially, but later be forced to return the funds if they are found during an audit to be non-compliant.
With proper tools and proactive communication, the process doesn’t need to be daunting. This guide outlines practical approaches for educating patients and establishing a standardized approach to the Medicare annual wellness visit that is scalable and easy to implement with staff members. In this guide, you'll also find that we’ve uncovered ways to simplify the following key requirements:
Many healthcare practices find that technological resources are essential to make delivering the annual wellness visit worthwhile. Technology can ease the human burden by automating steps toward better patient communication and meeting reporting and billing guidelines. When practices take a systematic approach to the Medicare annual wellness visit, everyone wins.
According to the Population Reference Bureau, the American population of people aged 65 and over (i.e., Medicare-eligible beneficiaries) is 46 million and is expected to more than double by the year 2060.
One of the greatest challenges medical practices face today is clearing up the confusion about the Medicare Annual Wellness Visit — more specifically, what it is and what it is not. Understandably, Medicare patients often erroneously assume that this is the equivalent of an annual physical exam. However, that is not the case. The headache that medical practices often face is the aftermath of the confusion, which can include everything from angry patients to coding errors that jeopardize reimbursement. The end result can be apathy and missed visits.
For health care providers to cut through the confusion, it’s essential to have a clear grasp of the differences in these two types of services and review what Medicare covers.
CMS notes that a "routine physical examination" is not covered by Medicare. As such, Medicare patients will be expected to cover the entire cost of the service (unless supplementary insurance provides coverage).
Unlike a yearly physical exam that can take about 30 minutes during which a physician measures all vital signs, thoroughly examines a patient from head to toe, and submits orders, like urine samples or blood tests, the Medicare Annual Wellness Visit does not provide such a thorough exam. Rather, it focuses on prevention planning and reviewing the medical history.
Instead of being guided by hands-on measurements, the Medicare annual wellness visit is driven by the health risk assessment. The HRA is a questionnaire and screening tool that provides an assessment about health status and provides feedback about actions that can be taken to reduce risks and promote health. Patient communication when performing the health risk assessment is key.
The provider works with patients to develop a personalized prevention plan, which requires the following:
In addition, providers may assess for cognitive impairment or look for signs of Alzheimer's disease or dementia. Medicare patients pay nothing for the annual wellness visit; however, they must be eligible for the service. Medicare.gov notes that beneficiaries with Medicare Part B for longer than a year are eligible once every 12 months.
It should be noted that during the first 12 months, a patient who is newly covered by Medicare Part B is also eligible for an initial preventive physical examination, or IPPE, to review medical and social history as well as health screenings that can include flu shots, vision tests, routine measurements, and referrals for other care. This visit, which is commonly referred to as a "Welcome to Medicare" visit, is covered only once and only in the first 12 months of coverage.
To adequately educate their patients about coverage and efficiently execute an annual wellness visit, providers need a clear outline of what should happen before, during, and after each visit.
Before the visit, practices should take the following steps:
During the visit, a patient should be educated to expect the following:
After the visit, providers should complete the following:
Crucial for practices to understand is that Medicare does not require annual wellness visits be performed only by a patient’s primary care physician, despite some definitions indicating such. According to an independent reference tool Medicare Interactive: “The annual wellness visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan.”
Medical practices should understand the distinction between “performing” or “providing” the service. "Perform" in this context means the ability to complete the AWV with the patient under the "general supervision" of a provider, with general supervision meaning the service is furnished under the physician's overall direction and control but the physician's presence is not required. "Provide" in this context means an individual is the actual billing provider of the Medicare annual wellness visit, i.e., holder of the National Provider Identifier (NPI) in the Medicare claim.
In addition to MDs — which includes cardiologists and other specialists — and DOs, other healthcare professionals who can provide the Medicare annual wellness visit are as follows:
It’s also worth noting that an AWV can sometimes be provided via telehealth.
Now let’s examine who can perform the AWV. Since the AWV can be conducted by clinical staff under the supervision of a provider, the broader answer to "who can perform the Medicare annual wellness visit" is anyone a provider has oversight of and trusts. If this categorization sounds rather broad, that's because it is — and it encompasses more than most understand. For instance, while the vast majority of practices use medical assistants or other "clinical staff,” under supervision, practices can even use contracted staff or engage in collaborative partnerships like those with pharmacists.
With such a broad definition, time-strapped providers can optimize efficiency using their clinical staff to offer more services. Perhaps no healthcare professional has more capacity to play an increased role as the pharmacist. In fact, a new healthcare delivery model is emerging, and practice administrators and providers are taking note of the value of incorporating a pharmacist into their practice care team. With the addition of a pharmacist, a practice can enhance the delivery of positive patient outcomes and improve medication and treatment adherence rates, all while reducing the overall cost of delivering good patient care and possibly growing volume in the process.
Together, the PCP and pharmacist team can encourage better patient adherence to treatment regimens, thus improving CMS measure scores that can preserve or boost reimbursement. Some practices even choose to integrate pharmacists into their practice to accomplish these goals. Notably, pharmacist integration is not likely to be as simple as "plug and play." Rather, as a Pharmacy Practice article notes, fully realizing the value of adding pharmacists to the team to conduct annual wellness visits will require an ongoing emphasis on interprofessional training.
One way to achieve a pharmacist-PCP partnership could be to hire a pharmacist. Another popular way to integrate a pharmacist into the care team is through a collaborative practice agreement (CPA) that would allow the pharmacist to come into a practice on a contract basis to perform annual wellness visits.
CMS takes no position on the particular tasks that should and should not be performed by specific members of such a team. Rather, CMS states that it believes it is better for the supervising physician to assign tasks to appropriate team members.
Confused? You're not alone. This article sorts out the differences between a traditional yearly physical and the AWV.
Many providers question whether providing the Medicare annual wellness visit is worth their time and resources. However the evidence shows that it can clearly be a net positive, if approached correctly. To be sure, the large Medicare-eligible population represents a great portion of the market, which can generate recurring income for a practice.
With a streamlined and clear plan, the Medicare annual wellness visit delivers the following advantages to providers:
What are the benefits of the Medicare annual wellness visit to patients? They include the following:
Medical software plays an essential role in the logistics of providing and documenting services by ensuring each visit is complete and eliminating human error in meeting requirements.
Now that you have a general understanding of the scope of the challenges associated with conducting the annual wellness visit, it’s easier to see why establishing a template for providing the Medicare AWV is of great value for addressing the time constraints of a busy practice and staff. A major component of any template focuses on delivering patient education in a standardized and consistent manner.
A customizable, holistic wellness platform can aid staff and patients with education by improving eligibility verification, patient outreach and intake, billing and coding, documentation requirements, and compliance.
A worthwhile goal for practices is to expedite completion of the Medicare annual wellness visit while still meeting patient needs and requirements. We have outlined 5 steps to take to better prepare patients for the AWV:
Medical providers who have increased the number of Medicare annual wellness visits performed and done so efficiently have at least one thing in common: They are strategic about their approach. The best way to accomplish this is to establish a systematic and scalable visit template covering everything from start to finish. A template eliminates planning hours and also prompts staff to proactively document and evaluate patient health risks. By simplifying the process, more patients can be served in the same amount of time, allowing for more revenue opportunities.
Important components that all annual wellness visit templates must include to meet Medicare requirements are as follows:
It’s key to integrate any template into the clinic’s existing patient management system.
In addition to determining which staff members will be responsible for providing different aspects of the service, you must also plan for how the Medicare annual wellness visit will integrate into established processes.
Check out our AWV Toolkit and download five helpful resources to get started.
A big piece of the puzzle for making preventive services viable requires medical practices to complete coding and billing of the Medicare annual wellness visit accurately. Doing so helps ensure practices earn full reimbursement and can protect practices from penalties incurred from failed coding audits.
Though a comprehensive review of all Medicare codes associated with the Medicare annual wellness visit would be overly burdensome, it is beneficial to review some of the most common codes used: G0402, G0438, and G0439.
Why is correct coding so important? In addition to ensuring accuracy to avoid rejected reimbursement, another reason is potential missed revenue. For example, the G0438 code is reimbursed at a rate that is nearly 50% higher than G0439. If a medical practice regularly fails to use the G0438 code for the initial Medicare annual wellness visit and uses G0439 instead, it could mean a significant loss of revenue.
In addition to these primary visit codes, a select list of other codes may be billed for services performed during a Welcome to Medicare or annual wellness visit. Many of these codes have guidelines that require them only to be used with specific services after meeting certain criteria.
One of the biggest hurdles for medical office staff is staying up to date on changing guidelines and eligibility requirements that affect coding and subsequent reimbursement. Practices can avoid risking an audit by staying current on coding requirements. For example, codes often get replaced, such as G0436 (smoking cessation counseling for 3 to 10 minutes), which was replaced by 99406 (smoking and tobacco use cessation counseling). Such a revision is fairly common.
When your focus is on patient care, who has time to monitor fluctuating regulations? Fortunately, we’ve done some of that work for you.
In November 2019, the CMS issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) effective on or after Jan. 1, 2020.
We’ve picked out some of the highlights for review:
Telehealth, telemedicine, and related terms generally refer to the exchange of medical information from one site to another through electronic communication to improve a patient’s health.
While the ongoing and evolving response to the novel coronavirus (COVID-19) has thrust telehealth service into the spotlight, the reality is that telehealth delivery models were already on the rise. For 2020, CMS added the following codes to the list of telehealth services: HCPCS codes G2086, G2087, G2088, which describe a bundled episode of care for treatment of opioid use disorders.
As of March 6, 2020, and for the duration of the COVID-19 public health emergency, CMS stated that it will pay for professional Medicare telehealth services furnished to beneficiaries in all areas of the country in all settings. These visits will be considered the same as in-person visits and paid at the same rate as regular, in-person visits. Services covered include the Medicare annual wellness visit and Medicare preventive services. These temporary changes are meant to allow providers the opportunity to continue to care for their patients from afar while the threat of coronavirus remains high. CMS continues to update a blanket list of waivers for the duration of the emergency. Check its website for ongoing updates as they become available.
Since annual wellness visits may be conducted via audio-only telehealth (i.e., over the telephone) for the duration of the waiver, there are some essential considerations to keep in mind:
To maximize the benefit of the AWV using telehealth services, providers can also add the following preventive services:
View a full list of the services Medicare is allowing via telephone on the CMS website.
Providers who wish to expand or streamline Medicare annual wellness visit services must be careful. From the first contract to the last bill, one documentation error can jeopardize reimbursement. In addition, the time that it takes to wade through requirements can distract from patient care. The good news is that it doesn’t have to. Establishing a systematic approach to the Medicare annual wellness visit is the best course for delivering comprehensive preventive patient services.
When working to improve your process, it’s important to consider the following questions:
The best way to implement a template for the Medicare annual wellness visit across your clinic is through a single preventive care platform that compliments your existing system for maintaining electronic health records.
With patient care to focus on, many practices find that using an end-to-end software platform can help them manage the avalanche of documentation and coding requirements, eligibility requirements, patient communication forms, outreach efforts, and billing. In return, these practices can expect to significantly reduce the time spent per preventive visit per patient, expand revenue, and capture increased revenue. Having a "single source of truth" for staff who are taxed with other responsibilities also helps to ensure accurate billing and consistent care practices.
But above all else, the solution needs to help patients achieve better overall health. If you are looking for an all-in-one solution that allows you to automate your practice’s workflow and significantly increase revenue without requiring additional work, Prevounce may be a good fit for your organization or office. If you’d like to learn more about our platform, book a meeting with us here.
To get started on improving your current process or implementing a new one, check out our AWV Toolkit, which includes:
Not only can Prevounce streamline your AWV, but we can also provide a practice-specific, single-source wellness solution that makes preventive and chronic care management easier to prep for, perform, document, and bill.
Our platform serves practices, practitioners, accountable care organizations (ACOs), and hospitals so that everyone can be compliant and get reimbursed.