Well visits not just for kids anymore

Prior to the passage of health care reform, the Medicare reimbursement system didn't provide for much preventive care. There was the “Welcome to Medicare” visit, and that was about it, according to Mary M. Newman, FACP, an internist from Lutherville, Md., who spoke at Internal Medicine 2011.

“If you wanted to get paid by Medicare for giving preventive advice/wellness advice, you had to do it in that first year and it had to last 25 years,” she said to laughter from her audience. That situation has changed thanks to the Patient Protection and Affordable Care Act, which last year added annual wellness visits with no copayment or deductible to the Medicare benefit.

During her session on “Conducting a Wellness Visit,” Dr. Newman offered tips on how to maximize patient satisfaction and reimbursement. “It is a wellness visit and it is different from any kind of physical that you are currently doing,” she warned.

The unusual nature of the wellness visit begins with its physical exam, in which measurement of only height, weight, body mass index and blood pressure is required. “The physical is going to be shocking to the patient,” said Dr. Newman.

She recommends preparing patients for this surprise before they schedule their first wellness visits. “I started six months ago telling them about this benefit. I do it in a positive way: ‘Medicare is now covering an annual wellness visit but it's not the one you expect,’” she said. “Make sure that patients do not believe this is an executive physical.”

It may help to explain to patients that you were effectively providing these services for free before, or squeezing them into another kind of visit, Dr. Newman advised. However, practices that were charging Medicare patients for physicals under code 99397 may have to revise their coding.

“Many business-savvy physicians have been doing physicals on their Medicare patients at a commercial rate, not covered by Medicare. You're going to have to look very carefully if that's your practice's current policy, because now wellness visits are covered. They just have a different code,” she said. The code for the wellness visit is G0438 with a diagnosis of V.70. (For more on properly coding for annual wellness visits, see CPII Tips. )

Another important feature of the wellness visit is who can provide it—not only physicians, physicians' assistants and nurse practitioners, but also a health educator or registered dietician. The visit must be supervised by a physician, but it can be performed by any licensed practitioner. “You're going to want to think about which part of this could be done by someone else and how can you streamline it,” Dr. Newman said.

Some streamlining can be accomplished before the visit even begins. Medicare requires establishing a medical/family history and a list of current clinicians and suppliers (such as medical equipment or oxygen providers) involved in the patient's care. If this information is already in an electronic medical record, it may be easy to compile. (An EMR that pulls history into the current visit is also very helpful in avoiding missteps like forgetting that a patient's spouse has died, Dr. Newman noted in an aside.)

Otherwise, have the patient fill out a form. “Get them to do it in the waiting room. Get them to do it at home. You'll make your time much better spent,” said Dr. Newman. The patient-supplied history can go right into the record, although a clinician review of the data needs to be documented. “You want to make some statement that you reviewed it,” said Dr. Newman. “It wasn't a self-service physical.”

The presence or absence of cognitive impairment also needs to be documented in the wellness visit. Such screening can seem unnecessary in younger, healthier Medicare patients, Dr. Newman noted. “Do you have to do a mini-mental on a physicist? No. Do you have to give someone a large form? No. You have to consider, ‘Is there cognitive impairment?’”

Similarly, the required function and depression screening can be completed quickly and easily. Function may become apparent on the trip from the waiting room to the exam room, or from quick small talk about the patient's life. Any difficulty hearing will also probably be revealed in that conversation. Dr. Newman also suggested asking patients if they worry about falling, noting “This is a good screening question because a lot of people do not disclose their falls.” For depression, she recommended a two-question screen: “Have you lost interest or pleasure in doing things? Have you felt down, depressed or hopeless?”

Advance care planning is an optional component of the visit, and may be unwelcome in younger or healthier Medicare patients. “Discussing end-of-life issues in people who are still well is more difficult to do and not necessarily appreciated or useful,” said Dr. Newman.

Then it's time for the final unusual component of the annual wellness visit: the plan. “The plan is what is very different from anything most of us are doing. You have to list the patients' risk factors and conditions and make referrals if needed for weight loss, physical activity, smoking cessation [and] fall prevention,” Dr. Newman said. The plan should also list any screening tests that the patient will need over the next five to 10 years.

To assist with development of that list, Dr. Newman provided a quick run-through of Medicare coverage for screening tests.

• Abdominal aortic aneurysm: once, for men who've smoked and women with a family history, if a referral is given during the “Welcome to Medicare” exam.
• Bone density measurement: every 24 months in patients at risk for osteoporosis.
• Colon cancer: annual fecal occult blood testing, flexible sigmoidoscopy or screening colonoscopy every 48 or 120 months depending on risk.
• Diabetes: fasting blood glucose twice a year for high-risk patients.
• Immunizations: influenza annually, a hepatitis B series for high-risk patients, pneumococcus once, and shingles once (but paid under Part D).
• Mammograms: annually.
• Cholesterol screening: only every five years. “You may be doing this more often,” said Dr. Newman, noting that the challenge may be keeping track of when five years have passed and a test will be covered.
• Smoking cessation: eight visits in a year. “It is a generous benefit,” said Dr. Newman. “You can do it yourself. You can have someone in your office do it.”
• Nutrition counseling: three hours in the first year after diagnosis with diabetes or kidney disease and two hours annually thereafter. Many patients and physicians don't take full advantage of this benefit, Dr. Newman said.
• Prostate cancer: coverage for annual digital rectal exam (minus a 20% copayment) and prostate-specific antigen.
• Pelvic exam and Pap test: every two years or yearly for high-risk patients with no copay or deductible.

Although they are not a standard component, the latter two exams could be incorporated into the wellness visit, Dr. Newman suggested. “Perhaps with some of your healthier beneficiaries, this is a way to make it a little more well-reimbursed visit and make it clearer that you are doing more of a physical,” she said.

There's currently debate among physicians about whether to provide other services at the time of a wellness visit, according to Dr. Newman. Even when warned about the nature of the appointment, some patients will likely arrive with a list of problems. “You have to decide whether in your workflow, you're going to do any problem-related visits or not,” she said.

If a non-physician is providing the wellness visit, it might be simpler to have the patient come back for another appointment. But if a problem has to be dealt with immediately, use modifier 25, and clearly document the situation. Dr. Newman offered an example: “The patient came in for his annual wellness visit. In the course of the annual wellness visit, I discovered he had a large ulcer on his big right toe. I spent 15 minutes evaluating his leg, the state of his diabetes, as well as making a referral for an X-ray and podiatry visit.”

In addition to adding in any necessary urgent care, internists should feel free to include their own priorities in the visit, Dr. Newman advised. “One of my partners loves to ask everybody if they're dizzy,” she said. “In my area, Lyme disease is huge, so I like to talk to them about tick abatement.”

Any preventive advice or screening referrals should be summarized in a take-home form for patients. Dr. Newman provided an example of her form, which lists when screenings were last performed and will be required again. At the bottom, there's a list of risk factors and recommendations for improvement in diet, exercise or other lifestyle factors. “Why don't we say, ‘You should lose 10 pounds' and write it down? Or, ‘You should double your exercise,’” said Dr. Newman.

On the other hand, if the patient is living a very healthy lifestyle, she notes that, too. “I write, ‘You're doing great’ or ‘A+’ or something. They don't get a grade on their health from anybody,” she said. The report card design of Dr. Newman's take-home form inspired one of her patients to say she would put it on the fridge. “I thought, ‘Oh my gosh, my patients have never had anything to put on the refrigerator,’” Dr. Newman said.

The effectiveness of these take-homes may be judged in a year, when it's time for patients' subsequent annual wellness visits. The subsequent visits are coded as G0439 and are substantially similar to the initial one, requiring weight, height, blood pressure and cognition checks and updates of the history, risk factors, clinicians and plan. At least 365 days have to pass between wellness visits.

Dr. Newman offered some additional scheduling tips. If a patient is within his or her first year on Medicare, a “Welcome to Medicare” physical should be provided, instead of the wellness visit. Because annual wellness visits are fully covered by Medicare, practices may want to schedule them in January and February, when payments are traditionally slower. “Do it in the beginning of the year, because you'll get paid faster than for copayment/deductible services,” said Dr. Newman.

The fee for the visit is about a level 4, but it varies regionally, she added. Physicians should check with their local Medicare carrier to get specifics on payments and requirements.

Dr. Newman's final piece of advice to physicians embarking on wellness visits was not to worry. “The doctors [in my practice] the first week or two thought this was impossible to do,” she acknowledged. To start, the physicians needed a checklist of the required components of the visit and had to remind front office staff of the importance of determining whether a patient was on Medicare before the visit. But now, she said, the process flows right along. “The patients like the visit and the doctors have mastered the coding and organizational issues. It wasn't that difficult.”