"I'm calling to schedule that new Medicare physical I heard about on the news today." Sound familiar? This is what primary-care practices are now hearing and since only a few weeks separated the release of the Physician Fee Schedule Final Rule and the implementation on January 1, 2011, physician practices have been scrambling to get ready.
The Patient Protection and Affordable Care Act of 2010 added a new benefit for Medicare recipients called an Annual Wellness Visit. Contrary to patient and physician expectations, it is not a physical exam or preventive medicine service, as defined by CPT codes 99381-99397. In fact, those services remain noncovered and if billed they will be denied as routine by Medicare.
The initial Annual Wellness Visit has more in common with the unpopular Welcome to Medicare Visit, also called the Initial Preventive Physical Examination. Patients who are newly enrolled in Medicare are still — and only — eligible for the Welcome to Medicare Visit in the first year of their Medicare enrollment.
A patient is eligible for the initial wellness visit if she has been enrolled in Medicare for longer than 12 months and has not received a Welcome to Medicare visit in the past 12 months. Let's say a patient enrolls in Medicare on July 1, 2010. She is eligible for a Welcome to Medicare visit from July 1, 2010 until June 30, 2011. She schedules her visit on May 5, 2011. She will then be eligible for her first wellness visit after May 6, 2012 — one year after the Welcome to Medicare visit.
A different patient, however, enrolled in Medicare February 1, 2008. On January 1, 2011, he became eligible for the initial wellness visit. He calls immediately and is scheduled for February 5, 2011 for his initial visit.
This visit requires:
• Taking or updating his medical and family history;
• Establishing a list of current providers and suppliers of medical care;
• Height, weight, BMI calculation (or waist circumference), blood pressure, and "other routine measurements as deemed appropriate";
• Detection of any cognitive impairment that he may have by direct observation, with consideration of information from medical records, patient reports, concerns raised by family members;
• Review for the potential for depression based on use of an appropriate screening instrument;
• Review of his functional ability and level of safety, based on direct observation, or use of a screening questionnaire;
• Establishment of a written screening schedule, such as a checklist, for the next 5-10 years based on recommendations of the US Preventive Task Force and Advisory Committee on Immunization Practices, and the patient's health status, screening history, and age-appropriate covered Medicare services;
• Development of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway — including mental health conditions or risk factors, or conditions identified through an previously performed Welcome to Medicare Visit (or this visit), and a list of treatment options and their associated risks and benefits; and
• Furnishing of personalized health advice and referral, as appropriate, to health education or preventive counseling programs aimed at reducing identified risk and improving self management — including weight loss, smoking cessation, fall prevention, and nutrition.
(End of life planning was removed as a requirement.)
What's the code for the service? G0438: Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit.
The visit has 4.74 Relative Value Units, for a national payment of $159.25.
If you want more information on the Medicare Annual Wellness Exam, watch our 4-minute "Video Primer" here.
Betsy Nicoletti is the founder of Codapedia.com. She is the author of "A Field Guide to Physician Coding." She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at [email protected].
*Seniors and doctors alike are hot for the highly publicized new wellness visit under Medicare, but a story about claim denials from contractors is apparently causing a bit of alarm. Read, "Watch Out for Medicare Wellness Visit Glitches" to find out the details.