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Medent Quarterly User Group
Medent Quarterly User Group Kristin Cortese & Jamie Perry| 2.4.2015 V20.1 Upgrade: • Has anyone upgraded yet? • If so, any challenges? • Contact Medent to get upgraded if not done so already Medent Quarterly User Group 2.4.2015 ©2011 Proprietary and Confidential EPCS Identity Proofing • • • • • Mandatory for E-RX controlled substances Deadline of March 27th, 2015 Has anyone completed this process? Any feedback? V20.1 is needed to comply with this process Refer to attachments A & B Medent Quarterly User Group 2.4.2015 ©2011 Proprietary and Confidential Mass Portal Messages • Now available in V20.1 • Will have ability through DM/HM reports • Medent can build formulas per practice request or can use existing • Ex: If you wanted to send a mass reminder to all patients due for a mammogram, prior to running the report you would click the ‘Send Portal Message’ link, a message box appears similar to a triage and you can enter the message you would like the patient to receive. Medent Quarterly User Group 2.4.2015 ©2011 Proprietary and Confidential PQRS 2015 • If in the ACO you DO NOT have to report PQRS. We do GPRO reporting on behalf of all participants in the ACO Medent Quarterly User Group 2.4.2015 ©2011 Proprietary and Confidential HEALTHeLINK Updates • • • • • Subscribe & Notify: Attestation Form (att C & D) Discharge Med List Image Enabled Results Delivery CH Transcribed Reports HIE Module-V20.1 ONLY: Upload of CCD to HeL at the end of every visit • HEALTHeLINK Contact: – Steve Gates, ph#716-206-0993 x312 Fax#716-206-0996 – Email: [email protected] – Fill out attachment E and fax to HeL to request these services. Medent Quarterly User Group 2.4.2015 ©2011 Proprietary and Confidential Sidebar Setup and Review • Dr Chad Szymanski-IT Lead and Physician at PCWNY • Improve Staff & Provider Efficiency • Cut down on multiple clicks to find the info you need Medent Quarterly User Group 2.4.2015 ©2011 Proprietary and Confidential QUESTIONS/COMMENTS Annual Wellness Visit • Importance of AWV for ALL Medicare/Mgd Care patients • Overview of AWV requirements • Overview of New G Code for IHA Enhanced Wellness Visit • Refer to attachment E and ABC’s of providing the AWV and IPPE for further details Medent Quarterly User Group 2.4.2015 ©2011 Proprietary and Confidential Annual Wellness Visit • CPT GO402 is for the Welcome to Medicare Visit. - Payment is $155 -This code can only be billed when the services are provided within the first 12 months the patient is enrolled in Medicare Part B • CPT G0438 is for the Initial AWV. – Payment is $172.18 – Medicare pays for ONE G0438 per LIFETIME, can be billed 12 months after eff. date of beneficiaries part b benefits • CPT G0439 is for Subsequent AWV. – Pymt is $111.35 – Medicare pays for ONE G0439 per year after the Initial AWV • • TEMPLATE NAME : Medicare Well Visit *Same template for (3) Visits listed above You can bill an E&M code along with the AWV code as long as you append modifier-25 Medent Quarterly User Group 2.4.15 ©2011 Proprietary and Confidential • • • • • • Initial AWV description of visit Acquire Beneficiary History including: -Complete HRA (Health Risk Assessment), Acquire Beneficiaries medical/family history, review potential risk factors, review functional ability and level of safety Begin assessment, establish list of current providers/suppliers, assess cognitive function of beneficiary Counsel Beneficiary including: -Establish written screening schedule for beneficiary, list of risk factors and conditions along with interventions, providing personalized health advice and/or referrals if appropriate Subsequent AWV description of visit Update Beneficiary History Complete new assessment for that visit Counsel Beneficiary Medent Quarterly User Group 2.4.15 ©2011 Proprietary and Confidential *NEW* G8496- IHA Enhanced Annual Visit - IHA Medicare Advantage Plan ONLY - $300 Reimbursement. - No co-pay/coinsurance - Can bill annually - Cannot bill Annual physical within same CY as the Enhanced Annual Visit -You cannot bill an E&M code the SAME day as the Enhanced Annual Visit (EAV) -TEMPLATE NAME: Enhanced MCR Visit (IHA) Medent Quarterly User Group 2.4.15 ©2011 Proprietary and Confidential • • • • • • IHA Enhanced Annual Visit description of visit Review patients HRA Document status of EVERY medical condition, update Problem list, create goals for treatment and mgmt of conditions Complete Physical Exam Acquire Beneficiary History Counsel Beneficiary *Submit medical record for the Enhanced Annual Visit to IHA for payment via secure fax 716-250-7184, by mail to IHA’s QM department OR secure email to [email protected]* Medent Quarterly User Group 2.4.15 ©2011 Proprietary and Confidential IHA Enhanced Wellness Visit Template • Review approved template to document • Template has been added to ALL Adult Medent practices to use immediately • If you are currently on V20.1 there was additional set up involved so the template may not be available, please check with your Clinical Transformation Specialist. Medent Quarterly User Group 2.4.15 ©2011 Proprietary and Confidential Upcoming Events • Regional Meeting scheduled February 24th, 2015 Open to All physicians and managers Invite will be sent out through Ebrite Place: Millennium Hotel Time: 5:30 Representation from IHA and Blues will be there to further discuss proper billing for the Annual Visits • Next Medent User Group scheduled for May 13th at Noon • Please email Kristin Cortese with topics you would like discussed at our future User Groups. [email protected] Medent Quarterly User Group 2.4.15 ©2011 Proprietary and Confidential QUESTIONS/COMMENTS From: To: Subject: Date: Attachments: Cortese, Kristin "Fran M" Medent EPCS and Identity Proofing Tuesday, December 02, 2014 8:30:33 AM Medent EPCS.PDF Good Morning Fran! As you most likely know by, as of March 27 th 2015 ALL prescriptions (written in New York State) must be transmitted electronically, including controlled substances. In order to prescribe a controlled substance, all practitioners are required to go through an identify proofing process by the DEA, and at that time will be issued a security token. The token will need to be used each and every time a controlled substance is prescribed, thus electronically tramsitted. You can begin the Identity Proofing process NOW, by following the steps below. Attached also is a fax from Medent detailing the instructions and has additional resources as well. Once you have completed the Identify proofing process, you will need to submit a form to Medent, putting you at the front of the queue for the Medent Version 20.1 upgrade, as soon as it is available. In order to initiate the identity proofing and token issue process, all practitioners must complete this on their own. IdenTrust is the company Medent has partnered with who will be doing the Identify Proofing as well as issuing the security tokens. Steps to follow for Identity proofing with IdenTrust and Medent 1. Go to www.identrust.com/igc/medent/ (in step 2 select “You want to buy a new USB token) 2. Complete form. You must provide name, address, phone, DOB, SS#, a credit card number in your name and your driver’s license #. (Keep in mind, the time to complete the process on this site to the time you receive your token in the mail is about a week.) 3. Once you receive your token in the mail, you must setup the token on each and every computer that the practitioners will prescribe medications from. In Medent’s version 20.1 online manual you can find details on EPCS including how to install and set up your token. 4. Once every practitioner has received their tokens and set them on each computer they use, fill out the Medent form attached in this email (page 2) and fax it to Medent. Follow the fax instruction on the form. Again, by faxing in this form it will put you at the front of Medent’s queue for the V20.1 upgrade. In this upgrade the EPSC functionality will be available. Without this upgrade (and going through the identify proofing and token issue process) you will not be in compliance for the March 27 th deadline set by NYS and the DEA. Please let me know if you have any questions throughout this process and as more information becomes available to CMP and Medent about EPCS we will let you know. Thank you and have a great day! REQUEST FOR HEALTHeLINK Services PRACTICE NAME: _______________________________________________ PRIMARY CONTACT:_____________________________________________ PHONE #: ______________________________________________________ PLEASE CHECK THE SERVICES BELOW THAT YOU WOULD LIKE HEALTHeLINK TO CONTACT YOU ABOUT: SERVICE #1: SUBSCRIBE AND NOTIFY /ADT Alert Notification SERVICE #2: CHS DISCHARGE MED LIST * SERVICE #3: IMAGE ENABLED RESULTS DELIVERY * Current Sources available: ECMC, Windsong, Southtowns Radiology Please list additional sources that your group may be interested in:_________________________ SERVICE #4: CHS TRANSCRIBED REPORTS * OPTION #5: CCD UPLOAD @ CLOSE OF ENCOUNTER * *Requires existing HEALTHeLINK Results Delivery Interface (HIE/CCD Module) PLEASE FAX COMPLETED FORM TO THE FOLLOWING: HEALTHeLINK ATTN: STEVE GATES FAX#: 716-206-0996 Upon receipt, a HEALTHeLINK Account Manager will contact you about enabling these services. RE: New for 2015: Independent Health Medicare Advantage $300 Enhanced Annual Visit Dear Physician: Independent Health is pleased to introduce a new “Enhanced Annual Visit” for your Medicare Advantage patients. This visit incorporates many of the services that you already provide to your patients during your preventive and wellness visits, with an expanded focus on assessment and management of your patients’ chronic diseases. Independent Health will reimburse you $300 for this visit between January 1 and June 30, 2015 in order to adequately compensate you and your team for the time it takes to conduct this enhanced visit. This visit has no member copayment to further encourage your patients to engage in this important visit. In our efforts to make this new enhanced annual visit as smooth as possible for your practice and patients, we have enclosed our Enhanced Annual Visit Program Guide, along with additional materials which outlines a few simple steps to complete the visit. If you have any questions, please contact [email protected]. You may also call (716) 505-8560 with your questions and leave a message. A member of our team will return your call. Thank you for your continued commitment to serving your patients. Sincerely, Thomas J. Foels, M.D., M.M.M. Executive Vice President and Chief Medical Officer PROGRAM GUIDE Independent Health’s Enhanced Annual Visit for Medicare Advantage Plans Effective January 1, 2015 This new “Enhanced Annual Visit” for your Medicare Advantage patients, available January 1, 2015, incorporates many of the services that you already provide to your patients during your preventive and wellness visits, with an expanded focus on assessment and management of your patients’ chronic diseases. The most efficient way to conduct the “Enhanced Annual Visit” would be to engage your office staff and prepare for the patient’s visit in advance. Your administrative and clinical support staff can play a significant role at the time of the patient’s visit as well. To support you and your staff in conducting these visits as easily and smoothly as possible, we have outlined four steps in this guide and enclosed the following in this packet: Step 1: Getting started and preparing for the patient visit • Enclosure 1a: Patient Roster • Enclosure 1b: Health Risk Assessment • Enclosure 1c: Gaps in Care Step 2: The patient visit • See page 2 for details on conducting the patient visit Step 3: Billing and coding • Enclosure 3a: Helpful Coding Tips • Enclosure 3b: Reimbursement Policy Step 4: Submitting the visit medical record • See page 3 for the address to submit the documentation Please see page 2 to begin. 1 STEP 1: GETTING STARTED PREPARE FOR THE PATIENT VISIT P Identify all of your Independent Health Medicare Advantage members by referring to the enclosed patient roster (Enclosure 1a). P Schedule the appointment with your patient. Many patients may already have an upcoming appointment on your schedule. See if this existing appointment will allow you the time necessary to conduct the Enhanced Annual Visit. • Remember to remind your patients (and staff) that this visit will have no member copayment. P Complete the Health Risk Assessment (Enclosure 1b). We recommend you mail or e-mail the Health Risk Assessment (HRA) to the patient prior to the visit. Copies of the enclosed HRA are available upon request, or you may use a CMS-compliant version. P Prepare for the patient’s office visit in advance by reviewing their medical record at least one week prior to their appointment. • Note any screening tests or vaccines that are due. • Note any “gaps in care” (Enclosure 1c). • Review the patient’s past medical history and note which specialist they are seeing (for what and how frequently), hospitalization, and ER/Urgent care visits. P Begin to make some decisions in advance of the patient’s visit: • What are your major clinical objectives for the coming year? • What specialists need to be involved or no longer involved in their care? STEP 2: THE PATIENT VISIT CONDUCT THE PATIENT OFFICE VISIT BY JUNE 30, 2015 P At the time of the visit: • Review the patient’s HRA and make it part of your permanent clinical record. Document discussions related to issues noted by patient on HRA. • Document the status of each and every medical condition, including goals for treatment and management plans for each active problem. Remember to update problem list. • Discuss any changes you might recommend in specialty physician referrals (i.e. which are no longer necessary and which can be modified). • Document standard visit elements: vital signs, interval history, past history, family history, medication reconciliation, review of systems, physical examination, update medication, problem and health maintenance lists, impression/assessment, plan and counseling of patient. P Provide a summary of the visit to the patient, including when to expect follow-up on test results and recommendations related to the HRA. 2 STEP 3: BILLING AND CODING (Enclosures 3a and 3b) P Precise diagnostic coding is necessary to capture the complexity of the patient population you serve. P Bill this service using code G8496 and refer to the coding tips to assure precise diagnostic ICD-9 coding to accurately capture the complexity of the patient population you serve: • List each and every active diagnosis, including those identified and managed by specialists. • Be mindful of “Status Codes” STEP 4: SUBMIT MEDICAL RECORD P Submit the medical record for the Enhanced Annual Visit to Independent Health • Include with the visit note the HRA, problem, and health maintenance and medication lists (often embedded in visit note). SENDING THIS DOCUMENTATION For your convenience, you have three options to send this information: Secure Fax: 716-250-7184 Secure e-mail: [email protected] Mail: Attention: QM Department Independent Health 511 Farber Lakes Drive Buffalo, NY 14221 QUESTIONS? E-mail: [email protected] Phone: 716.505.8560 3 Enclosure 1b Name:________________________________ DOB:___________ Demographics/Living Arrangements 1. Is there anyone else involved with your health care decisions? ☐Self ☐Family ☐Power of Attorney ☐Public Fiduciary ☐Guardian ☐Spouse/Partner ☐Other If yes, Name:__________________________ Phone Number:____________________ 2. Do you have any special language and/or cultural needs? ☐Yes ☐No If yes, what are they?__________________________________________________ 3. What is your current living arrangement? (Mark all that apply) ☐Alone ☐With spouse/partner ☐Family member/friend ☐Paid Caregiver ☐Independent Living Facility / Senior Housing or apartment ☐Congregate or Assisted Living ☐Nursing Home Facility 4. Are you a caregiver for someone else? ☐Yes ☐No If yes, who? _________________________________ 5. Do you have a caregiver who provides you with any assistance? ☐Yes ☐No If yes, what type of assistance? _____________________________________________________ 6. Physical Characteristics: Hearing: ☐Good ☐Fair Vision: ☐Good ☐Fair ☐Poor ☐Poor ☐Good with Hearing Aid ☐Good with Glasses 7. Are you currently receiving any of the following services from an agency? (Check all that apply) ☐Visiting Nurse ☐Social Worker ☐Physical Therapy ☐Occupational Therapy ☐Speech Therapy ☐Home Health Aid ☐Adult Day Care Center ☐Transportation Service ☐Home Delivered Meds ☐Homemaker/Chore Service 8. Do you use any of the following special equipment? ☐Hospital Bed ☐Hoyer Lift ☐Bedside Commode ☐Wheelchair ☐Walker ☐Other ☐Grab bars ☐Cane 9. Do you receive any of the following special treatments? ☐Tube feeding ☐Tracheostomy Care ☐Wound Care ☐Chemotherapy ☐CPAP ☐Insulin Pump ☐Dialysis ☐Ostomy Care ☐Oxygen ☐Nebulizer Advance Care Planning 10. Have you completed a Living Will, Advance Directives, or other Health Care Wishes document? ☐Yes ☐No ☐I don’t know If yes, please bring a copy with you to your next appointment with our office. Health & Well Being 11. In general, how do you rate your health overall? ☐Excellent ☐Good ☐Fair ☐Poor 12. How many medications (prescription and over-the-counter) do you take on a regular basis? ☐None ☐1-4 ☐5-9 ☐10+ Please bring a list of prescription and over-the-counter medications with you on your next appointment with our office. 13. Without wanting to, have you lost 10 pounds or more in the past 2 months? ☐Yes ☐No 14. In the past 6 months, how many times have you… None 1 Visited a doctor’s office or clinic? ☐ ☐ Gone to an emergency room or Urgent ☐ ☐ Care Center? Stayed overnight as a patient in a ☐ ☐ hospital? 2 ☐ ☐ 3 ☐ ☐ 4-5 ☐ ☐ 6+ ☐ ☐ ☐ ☐ ☐ ☐ 15. Do you currently see 3 or more doctors on a regular basis? ☐Yes ☐No Please bring a list of doctors you see regularly with you to your next appointment with our office. 16. Alcohol Use: ☐Yes ☐No How many drinks per day? __________ How many drinks per week? ___________ 17. How often do you use prescription medication other than exactly as prescribed to you? ☐Never ☐Sometimes ☐Often How often do you use recreational or illegal drugs? ☐Never ☐Sometimes ☐Often 18. In the last 30 days have you used tobacco? Smoked ☐Yes ☐No Smokeless ☐Yes ☐No If you’ve smoked or used smokeless tobacco recently, would you be interested in quitting tobacco within the next month? ☐Yes ☐No 19. How often do you feel sad or depressed? ☐Never ☐Sometimes ☐Often How often do you feel anxious or nervous? ☐Never ☐Sometimes ☐Often ☐Always ☐Always 20. Do you have a history of emotional or psychiatric problems or have you ever seen a mental health professional? ☐Yes ☐No 21. In the past 7 days, how many days did you exercise, such as a brisk walk, for at least 20 minutes per day? ☐1 ☐2 ☐3 ☐4 ☐5 ☐6+ ☐I did not exercise 22. Do you, like many people, have problems with bladder control or getting to the bathroom on time? ☐Yes ☐No 23. In the past 7 days, how much did pain interfere in your day-to-day activities? ☐Not at all ☐A little bit ☐Somewhat ☐Quite a bit ☐Very much 24. In the past year, have you had any of the following screening tests or vaccines? I’ve done this in the past year Date Breast Cancer screening ☐Yes Colorectal cancer screening ☐Yes Cervical cancer screening (PAP) ☐Yes Bone Mineral Density screening ☐Yes Flu vaccine ☐Yes Pneumonia Vaccine ☐Yes Shingles Vaccine ☐Yes Eye Exam ☐Yes Dental Exam ☐Yes Please help me schedule an appointment ☐No ☐No ☐No ☐No ☐No ☐No ☐No ☐No ☐No ☐N/A ☐N/A ☐N/A ☐N/A ☐N/A ☐N/A ☐N/A ☐N/A ☐N/A ☐Yes ☐ Yes ☐Yes ☐Yes ☐Yes ☐Yes ☐Yes ☐Yes ☐Yes ☐No ☐No ☐No ☐No ☐No ☐No ☐No ☐No ☐No Activities/Safety 25. In the past year, have you fallen to the ground or floor? ☐None ☐1-2 times ☐4 times or more 26. Do you have any concerns about safety in your home? ☐Yes ☐No 27. How much difficulty do you have doing the following activities? Bathing: ☐No difficulty ☐Some Difficulty ☐Cannot do at all Using the toilet: ☐No difficulty ☐Some Difficulty ☐Cannot do at all Dressing: ☐No difficulty ☐Some Difficulty ☐Cannot do at all Eating: ☐No difficulty ☐Some Difficulty ☐Cannot do at all Getting in/out of bed or chairs: ☐No difficulty ☐Some Difficulty ☐Cannot do at all Walking: ☐No difficulty ☐Cannot do at all ☐Some Difficulty If you have difficulty with any items above, does someone help you with any of these tasks? ☐Yes ☐No ☐N/A ☐N/A ☐N/A ☐N/A ☐N/A ☐N/A ☐N/A ☐N/A ☐N/A 28. How much difficulty do you have doing the following activities? Taking medications: ☐No Difficulty ☐Some Difficulty ☐Cannot do at all Managing money: ☐No Difficulty ☐Some Difficulty ☐Cannot do at all Preparing meals: ☐No Difficulty ☐Some Difficulty ☐Cannot do at all Shopping for groceries: ☐No Difficulty ☐Some Difficulty ☐Cannot do at all Doing routine household chores: ☐No Difficulty ☐Some Difficulty ☐Cannot do at all If you have difficulty with any of the items listed above, does someone help you with any of these tasks? ☐Yes ☐No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You may also refer to the ICD-9-CM Official Guidelines for Coding and Reporting for more additional tips. 1. Be sure to review and update the Problem List. Document and code any current and active diagnoses from the problem list. It is highly recommended that any diagnoses that no longer exist be removed from the active problem list and be placed in either the patient medical history or the inactive problem list. 2. Review confirmed diagnoses from consultations, and add these diagnoses to your problem list and assessment and plan. Many complex diagnoses are assigned by the specialists that you refer your patients to. Be sure to add any additional diagnoses from consultations to have a complete and accurate picture of your patient’s health. 3. Be mindful of “Status Codes”: Major medical events that occurred in the past that influences current medical care. Please add status codes to your problem list and assessment and plan. Examples include: 412 - Old MI status V42.x - Major transplant status V45.11 - Renal dialysis status V12.54 - History of TIA or Stroke V44.x - Ostomy status (if still patent) V49.7x - Lower limb amputation status 4. Documentation of Chronic Obstructive Asthma If a patient has asthma but pulmonary function tests show persistent airway obstruction, please consider documenting and coding the more detailed diagnosis of Chronic Obstructive Asthma (493.20) in your encounter note. 5. Active Cancer vs. History of Cancer Document an active cancer diagnosis when malignancy is present, with either active treatment being provided, or “watchful waiting”. History of cancer (v-codes) should be documented when the cancer no longer exists and that patient is no longer receiving treatment, but still may require monitoring. 6. Major Depression vs. Depression Encounter note should clearly differentiate between Major Depression (296.2x) and Depression, not otherwise specified (311). The definition of Major Depression as per DSM-IV guidelines states: “Characterized by discrete episodes of at least 2 weeks’ duration (although most episodes last considerably longer) involving clear-cut changes in affect, cognition, and neurovegetative functions and interepisode remissions. Careful consideration is given to the delineation of normal sadness and grief from a major depressive disorder.” Always use a more specified diagnosis if one exists versus an unspecified diagnosis. 7. Diabetes with Complications – Two codes are required When a diabetic patient presents with complications, they are no longer considered an unspecified, uncomplicated diabetic. (250.00) Please document and code the more specific diabetes with complication codes when complications or manifestations exist due to diabetes. Examples include: Diabetes with Acute complications (ketoacidosis (250.1x), diabetic coma (250.2x), hyperosmolarity 250.3x) Diabetes with Renal complications (250.4x) Diabetes with Ophthalmologic complications (250.5x) Diabetes with Neurologic complications (250.6x) Diabetes with Peripheral Circulatory complications (250.7x) Per documentation and coding guidelines, please also document and code the complication. Examples include: PVD (443.9) CKD (585.x) Retinopathy (362.0x) Neuropathy (357.2) *Please note in this document that if any diagnosis code has an “x”, this must be replaced with the appropriate 4th or 5th digit before submitting the diagnosis on a claim. Medicare Advantage Enhanced Annual Visit (DRAFT) Policy Number: Pending Effective Date: Pending Sponsoring Department: Network Reimbursement - Professional Impacted Department(s): Clinical Quality Type of Policy: ☐ Internal ☒ External Applies to (Line of Business): ☐ ☐ ☒ ☐ Corporate (All) State Products, if yes which plan(s): ☐MediSource/FHP; ☐Child Health Plus Medicare, if yes, which plan(s): ☒MAPD; ☒PDP/EGWP Commercial, if yes, which type: ☐Large Group; ☐Small Group; ☐Individual Excluded Products within the Selected Lines of Business (LOB) This section is intended to list specific LOB products that are excluded from adhering to this policy (due to differences in law/regulations). If not applicable, please indicate N/A. Applicable to Vendors? Yes ☐ No☒ Purpose and Applicability: To outline billing and reimbursement guidelines for the Medicare Advantage Enhanced Annual Visit. Policy: Independent Health allows reimbursement for a Medicare Advantage Enhanced Annual Visit (EAV) that meets set criteria and encompasses services above and beyond that of a traditional annual wellness visit or preventive visit performed by a Primary Care Practitioner. The Medicare Advantage Enhanced Annual Visit (EAV) is billable to Independent Health under HCPCS Code G8496 for Medicare Advantage Members only. Medicare Advantage members are eligible for one (1) EAV per calendar year. Once an EAV is reimbursed Restricted Page |1 for a member it will exhaust the member’s annual benefit. Any additional Preventive or Annual Wellness Visits performed during the same calendar year, by the same provider group will be denied. Conversely, the EAV will be denied in the event a Preventive or Annual Wellness Visit is already performed during the same calendar year by the same provider group. In addition to including services traditionally performed during a preventive or annual wellness visit, the EAV includes assessment and management of the patients’ chronic diseases. Consequently, additional Evaluation and Management Services (i.e. 99201-99215) are not billable for managing your patient’s chronic conditions on the same date of service as the EAV. All counseling and/or behavioral change interventions are encompassed in the EAV and are not separately billable. Surgical procedures, laboratory services, radiologic procedures and other diagnostics are separately billable and payable with the EAV. Vaccines and their corresponding administration codes will continue to be separately reimbursable. If during an EAV the patient presents with an acute condition which is significant enough to require additional work to perform the key components of a problem oriented E/M, additional evaluation services above and beyond what is required for the EAV are billable as an additional new or established patient evaluation and management service. Note that the time spent during the EAV cannot count toward the new or established patient E/M. In order to receive payment for the Medicare Advantage Enhanced Annual Visit (EAV), all of the following criteria must be met. Upon record review, if all criteria are not met and well documented the payment may be retracted. Completion of a Health Risk Assessment (Independent Health form or other CMS compliant form). Review of the patient’s Health Risk Assessment (HRA) and make it part of your permanent clinical record. Document discussions related to issues noted by the patient on the HRA. Document the status of each and every medical condition (even those identified and managed by specialists), including goals for treatment and management plans for each active problem. Document standard visit elements: vital signs, interval history, past history, family history, medication reconciliation, review of systems, physical examination, update medication, problem and health maintenance lists, impression/assessment, plan and counseling of patient. Provide a summary of the visit to the patient, including when to expect follow-up on test results Medical and Chronic Condition Management (must be performed by a physician, nurse practitioner or physician assistant). Send documentation of the entire visit including the Health Risk Assessment from your medical record to the Independent Health Quality Management Department: Fax: 716-250-7184 E-Mail: [email protected] Mail: Attention: QM Department Independent Health 511 Farber Lakes Drive Buffalo, NY 14221 Restricted Page |2 The code(s) listed in this Independent Health policy may not be all-inclusive. Independent Health reserves the right to review and update the coding in this policy when necessary to meet coding changes. Inclusion of a code within this policy does not guarantee reimbursement for that service. Definitions References Related Policies, Processes and Other Documents Regulatory References List all regulatory references used within this policy. Version Control Sponsored By: Name sponsor: Anthony Montagna Title of sponsor: Vice President, Network Contract Management Signature of sponsor: Revision Date Restricted Owner Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Notes Page |3 Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Restricted Page |4 QUICK REFERENCE INFORMATION: The ABCs of Providing the Annual Wellness Visit (AWV) Please note: The information in this publication applies only to the Medicare Fee-For-Service Program (also known as Original Medicare). Medicare covers an Annual Wellness Visit (AWV) providing Personalized Prevention Plan Services (PPPS). Medicare covers the AWV for beneficiaries who are not within the first 12 months of their first Part B coverage period and have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months. You must provide, or provide and refer, all components of the AWV prior to submitting a claim for the AWV. This document is divided into two sections: the first explains the components included in the first AWV a beneficiary receives; and the second explains the components included in all subsequent AWVs. Please note, the AWV is a separate service from the IPPE, also known as the “Welcome to Medicare Preventive Visit.” The AWV includes a Health Risk Assessment (HRA). We included a brief summary of the minimum elements in the HRA. Additionally, the Centers for Disease Control and Prevention (CDC) published “A Framework for Patient-Centered Health Risk Assessments: Providing Health Promotion and Disease Prevention Services to Medicare Beneficiaries.” This framework includes sections about the history of HRAs, definition of the HRA framework and rationale for its use, HRA use and follow-up interventions that evidence suggests can influence health behaviors, and a suggested set of HRA questions. For more information about HRAs, refer to http://www.cdc.gov/policy/ohsc/HRA/FrameworkForHRA.pdf on the CDC website. Components of the FIRST AWV Providing PPPS: Acquire Beneficiary History Acquire Beneficiary History ■ Health Risk Assessment Elements ■ ■ ■ ■ ■ Collects self-reported information the beneficiary knows; You or the beneficiary can administer the health risk assessment before, or as part of, the AWV encounter; Takes into account the communication needs of underserved populations, persons with limited English proficiency, and persons with health literacy needs, and is appropriately tailored to their needs; Takes no more than 20 minutes to complete; and At a minimum, addresses the following topics: • Demographic data; • Self-assessment of health status; • Psychosocial risks; • Behavioral risks; • Activities of Daily Living (ADLs) including but not limited to: dressing, bathing, and walking; and • Instrumental ADLs including but not limited to: shopping, housekeeping, and handling finances. CPT only copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. ICN 905706 January 2014 1 Components of the FIRST AWV Providing PPPS: Acquire Beneficiary History (cont.) Acquire Beneficiary History ■ Establishment of the beneficiary’s medical/family history Elements At a minimum, collect and document the following: ■ ■ ■ ■ ■ Medical events in the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the beneficiary at increased risk; Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments; and Use of or exposure to medications and supplements, including calcium and vitamins. Review of the beneficiary’s potential Use any appropriate screening instrument for beneficiaries without a current diagnosis of depression, which you may risk factors for depression, including select from various available standardized screening tests designed for this purpose and recognized by national current or past experiences with professional medical organizations. depression or other mood disorders Review of the beneficiary’s functional ability and level of safety Use direct observation of the beneficiary, or any appropriate screening questions or a screening questionnaire, which you may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations to assess, at a minimum, the following topics: ■ ■ ■ ■ Ability to successfully perform ADLs; Fall risk; Hearing impairment; and Home safety. Components of the FIRST AWV Providing PPPS: Begin Assessment Begin Assessment ■ An assessment Elements Obtain the following measurements: ■ ■ ■ ■ Establishment of a list of current providers and suppliers Height, weight, body mass index (or waist circumference, if appropriate), and blood pressure; and Other routine measurements as deemed appropriate, based on medical and family history. Include current providers and suppliers that are regularly involved in providing medical care to the beneficiary. Detection of any cognitive impairment Assess the beneficiary’s cognitive function by direct observation, with due consideration of information obtained by way that the beneficiary may have of patient reports and concerns raised by family members, friends, caretakers, or others. Components of the FIRST AWV Providing PPPS: Counsel Beneficiary Counsel Beneficiary ■ Elements Establishment of a written screening Base written screening schedule on: schedule for the beneficiary, such as ■ Age-appropriate preventive services Medicare covers; a checklist for the next 5 to 10 years, ■ Recommendations from the United States Preventive Services Task Force (USPSTF) and the Advisory Committee as appropriate on Immunization Practices (ACIP); and ■ The beneficiary’s health status and screening history. 2 Components of the FIRST AWV Providing PPPS: Counsel Beneficiary (cont.) Counsel Beneficiary ■ ■ Elements Establishment of a list of risk factors Include the following: and conditions for which the primary, ■ Any mental health conditions or any such risk factors or conditions identified as a result of an IPPE; and secondary, or tertiary interventions ■ A list of treatment options and their associated risks and benefits. are recommended or underway for the beneficiary Furnishing of personalized health advice to the beneficiary and a referral, as appropriate, to health education or preventive counseling services Includes referrals to programs aimed at: ■ ■ ■ ■ ■ ■ Community-based lifestyle interventions to reduce health risks and promote self-management and wellness; Fall prevention; Nutrition; Physical activity; Tobacco-use cessation; and Weight loss. Components of SUBSEQUENT AWVs Providing PPPS: Acquire Update of Beneficiary History ■ Acquire Update of Beneficiary History Update of health risk assessment Elements ■ ■ ■ ■ ■ An update of the beneficiary’s medical/family history Collects self-reported information the beneficiary knows; You or the beneficiary can administer the update of health risk assessment before, or as part of, the AWV encounter; Takes no more than 20 minutes to complete; and At a minimum, addresses the following topics: • Demographic data; • Self-assessment of health status; • Psychosocial risks; • Behavioral risks; • ADLs, including but not limited to dressing, bathing, and physical ambulation; and • Instrumental ADLs, including but not limited to shopping, housekeeping, managing own medications, and handling finances. At a minimum, update and document the following: ■ ■ ■ Medical events in the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the beneficiary at increased risk; Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments; and Use of or exposure to medications and supplements, including calcium and vitamins. 3 Components of SUBSEQUENT AWVs Providing PPPS: Begin Assessment Begin Assessment ■ An assessment Elements Obtain the following measurements: ■ ■ ■ ■ An update of the list of current providers and suppliers, as that list was developed for the first AWV providing PPPS or previous subsequent AWV providing PPPS Weight (or waist circumference, if appropriate) and blood pressure; and Other routine measurements as deemed appropriate, based on medical and family history. Include current providers and suppliers that are regularly involved in providing medical care to the beneficiary. Detection of any cognitive Assess the beneficiary’s cognitive function by direct observation, with due consideration of information obtained by way impairment that the beneficiary may of patient reports and concerns raised by family members, friends, caretakers, or others. have Components of SUBSEQUENT AWVs Providing PPPS: Counsel Beneficiary Counsel Beneficiary ■ ■ ■ Elements Update of the written screening schedule for the beneficiary, as that schedule was developed at the first AWV providing PPPS or previous subsequent AWV providing PPPS Base written screening schedule on: Update of the list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended or underway for the beneficiary, as that list was developed at the first AWV providing PPPS or previous subsequent AWV providing PPPS Include any such risk factors or conditions identified. Furnishing of personalized health advice to the beneficiary and a referral, as appropriate to health education or preventive counseling services or programs Includes referrals to programs aimed at: ■ ■ ■ ■ ■ ■ ■ ■ ■ Age-appropriate preventive services Medicare covers; Recommendations from the USPSTF and the ACIP; and The beneficiary’s health status and screening history. Community-based lifestyle interventions to reduce health risks and promote self-management and wellness; Fall prevention; Nutrition; Physical activity; Tobacco-use cessation; and Weight loss. 4 Other Medicare Part B Preventive Services ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Bone Mass Measurements Cardiovascular Disease Screening Blood Tests Colorectal Cancer Screening Counseling to Prevent Tobacco Use for Asymptomatic Patients Diabetes Screening Tests Diabetes Self-Management Training (DSMT) Glaucoma Screening Human Immunodeficiency Virus (HIV) Screening Influenza, Pneumococcal, and Hepatitis B Vaccinations and their Administration Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD), also referred to as a CVD risk reduction visit IBT for Obesity Medical Nutrition Therapy (MNT) ■ ■ ■ ■ ■ ■ ■ Prostate Cancer Screening Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse Screening for Depression in Adults Screening Mammography Screening Pap Tests and Pelvic Examination Sexually Transmitted Infections (STIs) Screening and High Intensity Behavioral Counseling (HIBC) to Prevent STIs Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) NOTE: Eligible beneficiaries must receive a referral for an ultrasound screening for AAA from their physician, physician assistant, nurse practitioner, or clinical nurse specialist. For additional information on Medicare preventive services, visit http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ PreventiveServices.html or refer to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNProducts_list serv.pdf on the Centers for Medicare & Medicaid Services (CMS) website. Coding Use the following Healthcare Common Procedure Coding System (HCPCS) codes, listed in the table below, when filing claims for the AWV. AWV HCPCS Codes and Descriptors AWV HCPCS Codes Billing Code Descriptors G0438 Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit G0439 Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit Frequently Asked Questions (FAQs) Who may perform the AWV? A health professional, meaning a physician (a doctor of medicine or osteopathy), a qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist), or a medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of such medical professionals who are working under the direct supervision of a physician, must furnish the AWV. Who Can Get the AWV? Medicare covers an AWV for all beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period and who have not gotten either an IPPE or an AWV providing PPPS within the past 12 months (that is, at least 11 months have passed following the month in which the IPPE or the last AWV was performed). Medicare pays for only one first AWV per beneficiary per lifetime, and pays for one subsequent AWV per year thereafter. 5 Are Physician Assistants and Nurse Practitioners subject to the incident-to rules for the AWV or will they be reimbursed at the full payment rate? Preparing Eligible Medicare Beneficiaries for the AWV No. The AWV has its own benefit category. Therefore, it does not fall under the incident-to benefit category under section 1861(s)(2)(A) of the Social Security Act. Is the AWV the same as a beneficiary’s yearly physical? No, the AWV is a preventive wellness visit and is not a “routine physical checkup” that some seniors may get every year or 2 from their physician or other qualified non-physician practitioner. Medicare does not cover routine physical examinations. Are clinical laboratory tests part of the AWV? No, the AWV does not include any clinical laboratory tests, but you may make referrals for such tests as part of the AWV, if appropriate. Providers can help eligible Medicare beneficiaries get ready for their AWV by encouraging them to come prepared with the following information: ■ ■ ■ ■ Medical records, including immunization records; Family health history, in as much detail as possible; A full list of medications and supplements, including calcium and vitamins – how often and how much of each is taken; and A full list of current providers and suppliers involved in providing care. Do deductible or coinsurance/copayment apply for the AWV? No, Medicare waives both the coinsurance or copayment and the Medicare Part B deductible for the AWV. Can I bill a separate Evaluation and Management (E/M) service at the same visit as the AWV? Medicare may pay for a significant, separately identifiable, medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201 – 99215) you bill at the same visit as the AWV with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member. Which diagnosis code should I use for the AWV? You must report a diagnosis code. Since CMS does not require a specific diagnosis code for the AWV, you may choose any appropriate diagnosis code. Can I bill an electrocardiogram (EKG) and the AWV on the same date of service? Generally, you may provide other medically necessary services on the same date of service as an AWV. The deductible and coinsurance/copayment apply for these other medically necessary services. How do I know if a beneficiary already got his/her first AWV from another provider and know whether to bill for a subsequent AWV even though this is the first AWV I provided to this beneficiary? You have different options for accessing AWV eligibility information depending on the jurisdiction in which you practice. You may be able to access the information through the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS), as well as HETS User Interface, through the provider call center Interactive Voice Responses (IVRs). CMS suggests that providers check with their MAC to see what options are available to check beneficiary eligibility. If a beneficiary has never had an IPPE, does Medicare cover an Ultrasound Screening for AAA ordered based on an AWV referral? No, Medicare does not cover the ultrasound screening for AAA when ordered based on an AWV referral. Medicare coverage for a one-time ultrasound screening for AAA depends on the beneficiary meeting certain eligibility requirements, including getting a referral as a result of an IPPE. CPT only copyright 2013 American Medical Association. All rights reserved. 6 Resources Resource Website CMS FAQs about the AWV https://questions.cms.gov/faq.php?id=5005&rtopic=1991&rsubtopic=7749 “Medicare Benefit Policy Manual” – Publication 100-02 Chapter 15 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf “Medicare Claims Processing Manual” – Chapter 12, Section 30.6.1.1 Publication 100-04 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Chapter 18, Section 140 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf Medicare Learning Network® (MLN) Guided Pathways (GPs) The MLN GPs help providers gain knowledge on resources and products related to Medicare and the CMS website. For more information about preventive services, refer to the “Coverage of Preventive Services” section in the “MLN Guided Pathways: Basic Medicare Resources for Health Care Professionals, Suppliers, and Providers” booklet at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/Guided_ Pathways_Basic_Booklet.pdf on the CMS website. For all other GPs, visit http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWeb Guide/Guided_Pathways.html on the CMS website. MLN Matters® Article MM7079, “Annual http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM Wellness Visit (AWV), Including 7079.pdf Personalized Prevention Plan Services (PPPS)” MLN Matters® Article SE0711, “Reminder – Medicare Now Provides Coverage for Eligible Medicare Beneficiaries of a One-Time Ultrasound Screening for Abdominal Aortic Aneurysms (AAA) When Referred for this Screening as a Result of the Initial Preventive Physical Examination (“Welcome to Medicare” Physical Exam)” http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE 0711.pdf MLN Matters® Article SE1338, “Improve Your Patients’ Health with the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)” http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE 1338.pdf Preventive Services Educational Products http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/education_ products_prevserv.pdf 7 Resources (cont.) Resource Website Preventive Services MLN Web Page http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ PreventiveServices.html or scan the Quick Response (QR) code on the right. “Providing the Annual Wellness Visit” Booklet http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Annual WellnessVisit-ICN907786.pdf “Resources for Medicare Beneficiaries” Fact Sheet http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BenePubFSICN905183.pdf This educational tool was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This educational tool was prepared as a service to the public and is not intended to grant rights or impose obligations. This educational tool may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. The Medicare Learning Network® (MLN), a registered trademark of CMS, is the brand name for official information health care professionals can trust. For additional information, visit the MLN’s web page at http://go.cms.gov/MLNGenInfo on the CMS website. Your feedback is important to us and we use your suggestions to help us improve our educational products, services and activities and to develop products, services and activities that better meet your educational needs. To evaluate Medicare Learning Network® (MLN) products, services and activities you have participated in, received, or downloaded, please go to http://go.cms.gov/MLNProducts and in the left-hand menu click on the link called ‘MLN Opinion Page’ and follow the instructions. Please send your suggestions related to MLN product topics or formats to [email protected]. Check out CMS on: Twitter LinkedIn YouTube 8 QUICK REFERENCE INFORMATION: The ABCs of Providing the Initial Preventive Physical Examination (IPPE) Please note: The information in this publication applies only to the Medicare Fee-For-Service Program (also known as Original Medicare). The Initial Preventive Physical Examination (IPPE) is also known as the “Welcome to Medicare Preventive Visit.” The goals of the IPPE are health promotion and disease prevention and detection. This document explains the components included in the IPPE. You must provide, or provide and refer, all components of the IPPE prior to submitting a claim for the IPPE. Components of the IPPE: Acquire Beneficiary History Acquire Beneficiary History ■ 1. Review of the beneficiary’s medical and social history Elements At a minimum, collect the following: ■ ■ ■ ■ ■ ■ ■ ■ Past medical/surgical history (experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments); Current medications and supplements (including calcium and vitamins); Family history (review of medical events in the beneficiary’s family, including diseases that may be hereditary or place the beneficiary at risk); History of alcohol, tobacco, and illicit drug use; Diet; and Physical activities. 2. Review of the beneficiary’s potential risk factors for depression and other mood disorders Use any appropriate screening instrument for beneficiaries without a current diagnosis of depression recognized by national professional medical organizations to obtain current or past experiences with depression or other mood disorders. 3. Review of the beneficiary’s functional ability and level of safety Use any appropriate screening questions or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the following areas: ■ ■ ■ ■ Hearing impairment; Activities of daily living; Falls risk; and Home safety. CPT only copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. ICN 006904 January 2014 1 Components of the IPPE: Begin Examination Begin Examination ■ 4. An examination Elements Obtain the following: ■ ■ ■ ■ ■ 5. End-of-life planning, upon agreement of the beneficiary Height, weight, and blood pressure; Visual acuity screen; Measurement of body mass index; and Other factors deemed appropriate based on the beneficiary’s medical and social history and current clinical standards. End-of-life planning is verbal or written information provided to the beneficiary about: ■ ■ The beneficiary’s ability to prepare an advance directive in the case that an injury or illness causes the beneficiary to be unable to make health care decisions; and Whether or not you are willing to follow the beneficiary’s wishes as expressed in the advance directive. Components of the IPPE: Counsel Beneficiary Counsel Beneficiary ■ ■ Elements 6. Education, counseling, and referral based on the previous five components Based on the results of the review and evaluation services provided in the previous five components, provide education, counseling, and referral as appropriate. 7. Education, counseling, and referral for other preventive services Includes a brief written plan, such as a checklist, to be given to the beneficiary for obtaining: ■ ■ A screening electrocardiogram (EKG/ECG), as appropriate; and The appropriate screenings and other preventive services that Medicare covers. See page 3 for a list of other Medicare-covered preventive services. 2 Other Medicare Part B Preventive Services ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Bone Mass Measurements Cardiovascular Disease Screening Blood Tests Colorectal Cancer Screening Counseling to Prevent Tobacco Use for Asymptomatic Patients Diabetes Screening Tests Diabetes Self-Management Training (DSMT) Glaucoma Screening Human Immunodeficiency Virus (HIV) Screening Influenza, Pneumococcal, and Hepatitis B Vaccinations and their Administration Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD), also referred to as a CVD risk reduction visit IBT for Obesity Medical Nutrition Therapy (MNT) ■ ■ ■ ■ ■ ■ ■ Prostate Cancer Screening Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse Screening for Depression in Adults Screening Mammography Screening Pap Tests and Pelvic Examination Sexually Transmitted Infections (STIs) Screening and High Intensity Behavioral Counseling (HIBC) to Prevent STIs Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) NOTE: Eligible beneficiaries must receive a referral for an ultrasound screening for AAA from their physician, physician assistant, nurse practitioner, or clinical nurse specialist. For additional information on Medicare preventive services, visit http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ PreventiveServices.html or refer to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNProducts_list serv.pdf on the Centers for Medicare & Medicaid Services (CMS) website. Coding Use the following Healthcare Common Procedure Coding System (HCPCS) codes, listed in the table below, when filing claims for the IPPE. IPPE HCPCS Codes and Descriptors IPPE HCPCS Codes Billing Code Descriptors G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment G0403 Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report G0404 Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination G0405 Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination 3 Frequently Asked Questions (FAQs) Who may perform the IPPE? Either a physician (a doctor of medicine or osteopathy) or a qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist) must furnish the IPPE. Who Can Get the IPPE? All new Medicare beneficiaries who are within the first 12 months of their first Medicare Part B coverage period may get an IPPE. This is a one-time benefit. Are Physician Assistants and Nurse Practitioners subject to the incident-to rules for the IPPE or will they be reimbursed at the full payment rate? No. The Initial Preventive Physical Examination (IPPE) has its own benefit category. Therefore, it does not fall under the incident to benefit category under section 1861(s)(2)(A) of the Social Security Act. Is the IPPE the same as a beneficiary’s yearly physical? No, the IPPE is not a “routine physical checkup” that some seniors may get every year or 2 from their physician or other qualified non-physician practitioner. The IPPE is an introduction to Medicare and covered benefits, and focuses on health promotion and disease prevention and detection to help beneficiaries stay well. Medicare does not cover routine physical examinations. Are clinical laboratory tests part of the IPPE? No, the IPPE does not include any clinical laboratory tests, but you may make referrals for such tests as part of the IPPE, if appropriate. Do deductible or coinsurance/copayment apply for the IPPE? No, Medicare waives both the coinsurance/copayment and the Medicare Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening ECG (HCPCS codes G0403, G0404, or G0405). 4 Preparing Eligible Medicare Beneficiaries for the IPPE Providers can help eligible Medicare beneficiaries get ready for their IPPE by encouraging them to come prepared with the following information: ■ ■ ■ Medical records, including immunization records; Family health history, in as much detail as possible; and A full list of medications and supplements, including calcium and vitamins – how often and how much of each is taken. If a beneficiary enrolled in Medicare in 2013, can he or she have the IPPE in 2014 if it was not performed in 2013? A beneficiary, who has not yet had an IPPE and whose initial enrollment in Medicare Part B began in 2013, is eligible for an IPPE in 2014, as long as it is done within 12 months of the beneficiary’s first Medicare Part B enrollment effective date. Can I bill a separate Evaluation and Management (E/M) service at the same visit as the IPPE? Medicare may pay for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201 – 99215) billed at the same time as the IPPE when billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member. Which diagnosis code should I use for the IPPE? You must report a diagnosis code. Since, the Centers for Medicare & Medicaid Services (CMS) does not require a specific diagnosis code for the IPPE, you may choose any appropriate diagnosis code. CPT only copyright 2013 American Medical Association. All rights reserved. 5 Resources Resource Website CMS FAQs about the IPPE https://questions.cms.gov/faq.php?id=5005&rtopic=1991&rsubtopic=7747 “Medicare Benefit Policy Manual” – Publication 100-02 Chapter 15 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf “Medicare Claims Processing Manual” – Chapter 12, Section 30.6.1.1 Publication 100-04 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Chapter 18, Section 80 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf Medicare Learning Network® (MLN) Guided Pathways (GPs) The MLN GPs help providers gain knowledge on resources and products related to Medicare and the CMS website. For more information about preventive services, refer to the “Coverage of Preventive Services” section in the “MLN Guided Pathways to Medicare Resources: Basic Medicare Resources for Health Care Professionals, Suppliers, and Providers” booklet at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/ Downloads/Guided_Pathways_Basic_Booklet.pdf on the CMS website. For all other GPs, visit http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/ Guided_Pathways.html on the CMS website. MLN Matters® Article MM6223, “Update http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM to the Initial Preventive Physical 6223.pdf Examination (IPPE) Benefit” MLN Matters® Article SE0711, http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE “Reminder – Medicare Now Provides 0711.pdf Coverage for Eligible Medicare Beneficiaries of a One-Time Ultrasound Screening for Abdominal Aortic Aneurysms (AAA) When Referred for this Screening as a Result of the Initial Preventive Physical Examination (“Welcome to Medicare” Physical Exam)” MLN Matters® Article SE1338, “Improve http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE Your Patients’ Health with the Initial 1338.pdf Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)” Preventive Services Educational Products http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/education_ products_prevserv.pdf 6 Resources (cont.) Resource Website Preventive Services MLN Web Page http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ PreventiveServices.html or scan the Quick Response (QR) code on the right. “Resources for Medicare Beneficiaries” Fact Sheet http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BenePubFSICN905183.pdf 7 This educational tool was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This educational tool was prepared as a service to the public and is not intended to grant rights or impose obligations. This educational tool may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. The Medicare Learning Network® (MLN), a registered trademark of CMS, is the brand name for official information health care professionals can trust. For additional information, visit the MLN’s web page at http://go.cms.gov/MLNGenInfo on the CMS website. Your feedback is important to us and we use your suggestions to help us improve our educational products, services and activities and to develop products, services and activities that better meet your educational needs. To evaluate Medicare Learning Network® (MLN) products, services and activities you have participated in, received, or downloaded, please go to http://go.cms.gov/MLNProducts and in the left-hand menu click on the link called ‘MLN Opinion Page’ and follow the instructions. Please send your suggestions related to MLN product topics or formats to [email protected]. 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