Create Order from Wellness Visit Chaos

By Jacqueline Nash Bloink, MBA, CPC-I, CHC

The Centers for Medicare & Medicaid Services (CMS) has begun a campaign to educate Medicare beneficiaries about preventive services, including wellness visits, available to them. There is even a YouTube clip to promote these visits. If CMS believes these visits are such a great service for the beneficiary, why do so many physicians cringe when they hear an appointment has been scheduled for such a service?

Evaluation and Management – CEMC

Manage Patient Expectations

Beneficiaries often expect a head to toe examination during the wellness visit, but this is not what it delivers. Office staff must begin to educate the beneficiary that the wellness visit is a plan of care. When the beneficiary understands the wellness visit was created to take a snap shot of his or her current health status, and the physician won’t be performing a physical examination, the situation will be better controlled—meaning fewer angry beneficiaries and more physicians willing to perform the service.

Staff should also inform beneficiaries they will not incur a co-pay for a wellness visit, but if another service is provided during the visit, there will be a co-pay for that portion of the visit.

CMS has many educational resources available to physician offices to assist with explaining wellness visits to patients, including a downloadable patient brochure.

Three Visit Types, Three Sets of Requirements

There are three types of wellness visits, each of which has different requirements.

1. G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment describes the “welcome to Medicare preventive visit.” The beneficiary can only receive this visit during the first year that he or she is eligible and enrolled in Medicare. If the patient does not exercise his or her right to request this visit during that first year, he or she will never again have the chance to request it.

During this visit, the beneficiary is eligible for a screening electrocardiograph (EKG) (G0403-G0405) and aortic aneurism ultrasound (AAU), if he or she meets the following requirements:

  • Patients may be eligible for the screening EKG if a referral is given during the welcome to Medicare preventive visit (G0402).
  • AAU is provided as a one-time screening if the beneficiary gets a referral as a result of the welcome to Medicare preventive visit (G0402). Eligible patients are those who either have a family history of abdominal aortic aneurysm or if the patient is male, aged 65-75, who has smoked at least 100 cigarettes during his lifetime, and the patient has never had an AAU paid for by Medicare during his or her lifetime.

For more detail on the EKG and AAU screenings, visit the CMS website: www.medicare.gov/navigation/manage-your-health/pre​ventive-services/preventive-service-overview.aspx).

2. After 11 full months have passed, the beneficiary is eligible for the next wellness visit. G0438 Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit describes the “initial Medicare wellness visit.” This visit can be performed at any point in the beneficiary’s life, but only once during his or her lifetime. This code was implemented by CMS in 2011.

3. After 11 full months have passed since the initial wellness visit, the beneficiary is eligible for the “subsequent” wellness visit (G0439 Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit). A beneficiary can request this visit every year (after 11 full months have passed between visits), if so desired.

You can find a summary of the requirements of all Medicare wellness visits on the CMS website.

Create a Template to Make Documentation Easy

If the physician’s office combined all of the components of each of the three visits together to create one master template, as shown in Example A, the beneficiary would get a few extra benefits each year, while making things easier for the physician.

Items in red represent the services the physician provided during the visit that may have not been needed during that particular visit, but were required in one of the other visits. If all 10 steps are performed during the G0402, G0439, or G0438 visit, the provider does need to stop and think which component he or she is missing, making life much easier for both physician and patient.

By following a template for documenting wellness visits, the staff becomes familiar with the steps, and patients become accustomed to the questions and are prepared to answer them each year.

The health care team at the office (medical assistant, licensed practical nurse, or registered nurse) may be able to assist the health care professional (nurse practitioner or physician assistant) in obtaining 75 percent of the information prior to the physician entering the room to talk with the patient. Each year, the physician will have a written description of the beneficiary’s lifestyle and will be better prepared to address various risks that the patient may face as he or she ages.

With the wellness visit well-documented, all that remains is scheduling next year’s wellness visit (remember: at least 11 full months after this visit).

Example A: 

10 Easy Steps to Document Medicare Wellness Visits

1. Patient completes the required “Health Risk Assessment Questionnaire” prior to the visit with the physician (this is new for 2012). Guidelines for creating a form with all of the necessary components can be found at the Centers for Disease Control and Prevention (CDC) website.

2. Office staff documents the patient’s height, weight, blood pressure, body mass index (BMI), and visual acuity.

3. Patient’s medical history, family history, and social history are discussed and documented. Special attention is paid to past illnesses, surgeries, allergies, and injuries. Family history is pertinent with hopes of catching high-risk areas that may be modifiable or identified with special screening tools. The social history will be helpful in documentation of substance abuse such as smoking or alcohol.

4. Patient is queried about current or past events of depression. Make sure to list the type of depression tool used to determine the risk. Examples of such tools might include PQ1, PQ2, or Zing.

5. List all current medications, including vitamin supplements.

6. List all current providers and suppliers that the patient is seeing (specialists, diabetic suppliers, etc.).

7. Assessment of functional ability and safety: This must include:

  • Hearing
  • Daily living activities
  • Risk of falling
  • Safety/home life/risks

8. Cognitive impairment assessment and observation. Information may also be obtained from the patient’s family, caregivers, or friends.

9. End-of-life planning and advance directives. Does the physician agree with this plan?

10. Written plan of preventive services that the patient is eligible for the next one to 10 years. The patient takes this plan when he or she leaves the office.

Jacqueline Nash Bloink, MBA, CPC-I, CHC, lives in Tucson, Ariz. and is director of compliance for Arizona Community Physicians.

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