Preventive Exams Medicare patients

bethb

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We have a situation where "preventive health care" and "preventive examinations" are scheduled for Medicare patients. Medicare denies payment, of course, and we are asked to code the visit to an established E&M code, because the Medicare IPPE and Annual Wellness Exam components are not met.

I may be thinking way too much, but when I see verbiage as [presents for] "preventive health care"; "patient here for check-up"; presents for "physical examination" my first thought is to be wary on changing the CPT code from a preventive to a problem-driven E&M code.

The documentation has minor problems notated in the A&P, all established problems. To me, these established problems, would not warrant a problem-driven E&M code, as I feel they are minor components and would be bundled with the preventive exam codes.

I'm stuck here. Does anyone have any suggestions on this? We are working to educate the providers and staff, which is a positive step! But I don't feel these visits should be changed. Is there any acceptable reasons that the visit can be changed from a preventive code to a problem-driven CPT code?

Thanks,
Beth
 

mgarciaManagement

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Preventive Exams Medicare Patients

There definitely needs to be education for the entire office on Medicare Wellness Visits (Preventive Exams). This includes anyone who schedules appointments, Medical Assistants, NPP, Physicians, billing, collections, insurance verification staff and managers. The Medicare Wellness Visits are NOT physicals and should not be mixed with problem issues. Keep them separate and everyone will be happy. The entire staff needs to make sure they stick with the policy and relay it to the patient. If the patient has issues when they come in then they need to address the problem issues if urgent enough, reschedule their Wellness Visit or make another appointment to address their issue.

First of all, were all the documentation requirements done during the Wellness Visit you had?

For an IPPE:
1. Medical History
2. Surgical History
3. Family History
4. Allergies,
5. Supplements
6. Alcohol Screening
7. Tobacco Screening
8. Illicit Drug Use Screening
9. Diet & Physical Activities
10. Depression Screening (PHQ-9)
11. Hearing Impairment (Questionnaire)
12. Activities of Daily Living (Questionnaire)
13. Fall Risk (Questions)
14. Home Safety (Questions)
15. EKG (only with IPPE)
16. Diabetes Screening (specific requirements when to do 82947, 82950 or 82951)
17. Examination (Ht, Wt, BMI, BP, Visual Acuity Screen, other factors based on medical/social history and current findings)
18. ACP (Advance Care Planning/End-of-life planning (Advance Directive)
19. Educate/Counsel/Refer (On the above 5 components)
20. Educate/Counsel/Refer (On Other Preventive Services)
Provide a Checklist for the beneficiary to obtain

There are some different items for the Initial Annual Wellness Visit (AWV) and for the Subsequent AWV.

So, do they have all of this documentation for the wellness visit you are referring to? Also, the Clinical Staff needs to change the way they enter the patient's Chief Complaint. The word "check-up" should not be allowed as a CC. What is the check-up for?

My suggestions for Chief Complaints:
Cough, sore throat, fever
Three month follow-up for high cholesterol
Six month diabetes follow-up and fatigue
Initial Preventive Physical Exam (IPPE)
Initial Subsequent Wellness Visit (AWV)
Subsequent Wellness Visit (AWV)

Hope this helped.
 

bethb

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Thank you very much for the information. The Medicare wellness exam components are not all met or documented in the note, so I am not inclined to code the AWVs or IPPEs. The patients present for a "preventive exams" or "physical exams", which are not covered by Medicare, but that information is not relayed to the patients at scheduling.

After the physical examination is done, there is documentation of the patient's chronic, but stable, conditions, such as HTN, DM, Osteoporosis. These are not "acute" conditions and the plans are increase or change medications, home BP monitoring, etc. I do not believe these types of conditions would justify an established office visit code (99212-99215), especially when the patient scheduled for and presented for a preventive exam or physical exam.
 

mgarciaManagement

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You are correct.

The Medicare MLN Education Tool called The ABCs of the Initial Preventive Physical Examination (IPPE) states on page 2, "This publication explains the elements in the IPPE. You must provide all components of the IPPE prior to submitting a claim for the service."

So, all elements must be provided before you can bill it. If they are missing some of the documentation for the required elements for the IPPE/AWV then you shouldn't bill it. I suggest notifying them of the sections they missed and then bill it once it is done. Some of the documentation may be on a questionnaire and scanned into the EMR.

Refilling medication is one thing, but if they are prescribing a new medication or added treatment plan (BP monitoring), there must be significant, separately identifiable, medically necessary services accompany the wellness visit.

This definitely needs to be addressed with the entire staff.

If it were me, I would make copies of Medicare's documentation showing how it needs to be separate and the elements required for the wellness visit; and ask them to review their documentation as they don't appear to justify both wellness visit and E/M visit.
 
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Ippv/awv

I work for an FQHC and we are trying to figure out how/if we can bill a separate visit with our IPPV/AWV. I don't think that we can cause our bill rolls up into the FQHC code. Also, we are under the impression that if a finding or a problem is presented the visit is no longer a Well visit and is considered a problem visit with and office E/M. Is this how others view this?

Melissa
Dayspring Family Health Center
 

amla12

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AWV with chronic condition follow-up?

I've seen the AWV billed (with modifier) at the same visits that are scheduled for follow up of patients' diabetes, hyperlipidemia, hypertension etc.
When almost everyone aged 65 or over, has at least one chronic condition (more often than not a mixture of chronic problems with at least one uncontrolled), perhaps we get to the point where some of this differentiation between preventive and problem visits becomes more a matter of semantics?
 
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