You and your patient have a lot of ground to cover. Here’s one way to get it all done.
Fam Pract Manag. 2005 Apr;12(4):27-31.
The new Welcome to Medicare exam revolves around preventive health care, something family physicians have always incorporated into their practice. But as you work out your routine for performing these visits, you might need to reframe your thinking about what constitutes a physical exam.
The new Medicare exam includes seven elements, and they add up to a patient encounter that is as much of a conversation as it is a physical exam. Making sure you cover all of the required elements in the allotted time takes a well-planned routine. If you haven’t already developed such a routine, this article suggests some time-saving strategies. The encounter form in this article will help you to ensure all elements of the initial preventive physical exam are completed. The form also should help you meet evaluation and management (E/M) documentation requirements.
The essential elements
As part of the Medicare Modernization Act (MMA), Medicare beneficiaries whose Part B coverage began after Jan. 1, 2005, and who are within six months of the effective date of their coverage are eligible for one initial preventive physical exam. The exam focuses on identifying modifiable risk factors for medical conditions that frequently affect the elderly, as well as education, counseling and referral for Medicare-covered preventive services.
Here are the seven required elements:
1. Review of comprehensive medical and social history. The purpose of this element is to identify modifiable risk factors for disease.
The medical history component should include illnesses, hospitalizations, surgeries, injuries, allergies, medications, supplements and vitamins. Social issues to address include alcohol, tobacco and illicit drug use; diet; and physical activities. The family history is performed to identify hereditary diseases or diseases that otherwise place the patient at increased risk for disease.
2. Review of risk factors for depression. This next element involves identifying depression and other mood disorders. The Centers for Medicare & Medicaid Services (CMS) does not recommend a specific depression screening tool. Instead, CMS states that you “may select from various available standardized screening tests designed for this purpose.”1
Many standardized depression screening tools are too cumbersome to use in a short office visit. One quick technique recommended by the U.S. Preventive Services Task Force (USPSTF) involves asking two questions: “Over the past two weeks, have you felt down, depressed or hopeless?” and “Over the past two weeks, have you felt little interest or pleasure in doing things?” An affirmative answer to either may be as effective as more detailed instruments in identifying a patient who needs further evaluation for depression.2
BILLING FOR A WELCOME TO MEDICARE VISIT
Along with settling on a new routine for the Welcome to Medicare exam, you’ll also want to make sure you understand its billing requirements.
For a complete overview, see “New Year, New Medicare Benefits,” FPM, February 2005, page 15.
3. Review of functional ability and level of safety. You have a lot of leeway with this element, which requires you to evaluate your patient’s hearing, activities of daily living, functional ability and level of safety. As with the depression screening, CMS accepts any appropriate screening test that is recognized by national medical professional groups.
For determining fall risk, I recommend following the American Geriatrics Society’s (AGS) clinical guidelines. According to the AGS, there are two tests that should trigger further patient evaluation: if your patient previously has received treatment for a fall, or if your patient takes longer than 30 seconds for an “Up & Go” test.3
The timed Up & Go test involves having the patient stand up from a chair, walk three meters, turn around, walk back to the chair and sit back down. If the patient takes longer then 30 seconds or seems unsteady, the test is considered positive for increased fall risk.
To identify functional challenges, the CDC advises screening your patients by inquiring about their instrumental activities of daily living (IADLs). This involves asking patients about troubles using a phone, using transportation, grocery shopping, preparing meals, doing housework, doing laundry, taking medications and managing money. Any limitation to their IADLs that you identify as being caused by a chronic condition warrants further evaluation.
While functional assessments have been researched extensively, less evidence exists for home safety screening. The CDC recommends that elderly patients improve home safety by removing tripping hazards in walkways, using non-slip mats in bathtubs and showers, placing grab bars next to the toilet and shower, placing handrails on both sides of a stairway and improving home lighting. It seems reasonable to question patients about these items during the initial preventive physical exam.
For the hearing evaluation, I plan to follow the USPSTF’s recommendation to simply question patients about their hearing function. There are, of course, more elaborate testing methods, but the USPSTF found insufficient evidence to recommend for or against them.4
Your screening for depression risk, functional ability and level of safety should be accompanied by further evaluation, including a full diagnostic workup, for any patients with positive responses. The workup can be performed in conjunction with the initial preventive physical exam, or the patient can be further evaluated later. CMS will allow a level-one or level-two E/M code with a -25 modifier attached to be billed with the initial preventive physical exam. If you conclude that the depression or fall risk does not warrant immediate care but will require a level-three or higher E/M service, it might be prudent to perform the full workup at a later date.
4. A focused physical exam. This should be an extremely focused physical exam. Height, weight, blood pressure and visual acuity are the only required components. No specific vision tests are mandated, but using the Snellen chart is appropriate.
5. Performance and interpretation of an electrocardiogram. Some offices have the capacity to handle this, and others will need to send the patient to another facility. Either way, the ECG results need to be incorporated into your patient’s medical record to complete the initial preventive physical exam.
If the patient is sent to another facility for the ECG, the order must read “ECG as part of the Welcome to Medicare Physical, codes G0366–G0368.” Medicare has instructed that physicians must order the ECG in a manner that helps to prevent use of codes for ECGs not related to the initial preventive physical exam.
6. Brief education, counseling and referral to address any pertinent health issues identified during the first five elements of the exam. CMS expects the amount of time required for this step to vary depending on the problems that you discovered in the first five elements.
7. Brief education, counseling and referral, with maintenance of a written plan (such as a checklist), regarding separate preventive care services covered by Medicare Part B. There are now 11 preventive services authorized under Medicare Part B. Coverage for the two newest ones, cardiovascular disease screening and diabetes screening, became effective on Jan. 1, 2005. For the full list, see “Preventive services covered by Medicare Part B.”
It is important that you thoroughly understand Medicare’s policy on these services before counseling your patient. Some services are covered at 100 percent of the Medicare allowable charge, and some services are covered at 80 percent of the Medicare allowable charge. In addition, some of the services are covered only if medically indicated.
Kent J. Moore, AAFP’s manager for health care and delivery systems, has written two FPM articles that cover these Part B services. “Another Ounce of Prevention” (November/December 2002, page 25) covers most of the benefits, and “New Year, New Medicare Benefits” (February 2005, page 15) summarizes the two new ones.
PREVENTIVE SERVICES COVERED BY MEDICARE PART B
Pneumococcal, influenza and hepatitis B vaccines
Screening Pap smear/pelvic exam
Prostate cancer screening
Colorectal cancer screening
Diabetes outpatient self-management training services
Bone mass measurements
Screening for glaucoma
Medical nutritional therapy for individuals with diabetes or renal disease
Cardiovascular screening blood tests
Diabetes screening tests
Put it in writing
A checklist or another method of documentation indicating that the seven elements of the initial preventive physical exam have been addressed must be maintained in the patient record. The encounter form has been designed to do that.
In addition, you are required to give your patient a written plan for obtaining the appropriate preventive services. I suggest that you make a copy of the form’s second page to give to the patient at the exam’s conclusion. If you want to get fancy, you could design a similar form with a duplicate page two, allowing you to keep the original and give the carbon copy to the patient.
MEDICARE INITIAL PREVENTIVE PHYSICAL EXAMINATION ENCOUNTER FORM
This form has been updated since its original publication date to reflect changes to Medicare's covered services. You can download the updated encounter form as a PDF here.
A timed exchange
Over time, you will become more adept at completing the initial preventive physical exam in a reasonable period. CMS considers the physician/non-physician provider time component of the initial preventive physical exam to be equivalent to a 30-minute 99203 (new patient, level-three E/M code).
To speed the process along, you could use preprinted patient education materials to counsel your patient. For some specific examples available on Familydoctor.org, AAFP’s patient education Web site, see “Preprinted handouts.” It would also be helpful to ask your patients to bring to the visit the “Guide to Medicare’s Preventive Services,” which each new beneficiary is receiving in their Welcome to Medicare package. It can be viewed or downloaded at http://www.medicare.gov/publications/pubs/pdf/10110.pdf.
Familydoctor.org has patient education materials regarding many of the preventive health issues covered in an initial preventive physical exam.
Breast cancer screening
Cardiovascular blood tests
Colon cancer screening
Prostate cancer screening
As you perfect your Welcome to Medicare exam routine, you should also refine how your office handles this new Medicare benefit before patients are even in the exam room. Identify new Medicare-eligible patients. Schedule the patients in a timely manner. Perform some of the screening before the face-to-face encounter.
The initial preventive physical exam is an opportunity for you and your newly enrolled Medicare patients to start thinking about Medicare-covered preventive services. Effective, efficient use of the initial preventive physical exam requires physicians and non-physician providers to understand the specific components of the initial preventive physical exam. A systems approach to identifying, educating and counseling patients regarding Medicare-covered preventive services may improve patient health and help physicians deliver the initial preventive physical exam in a financially sound manner.
Dr. Card is associate director of the Family Practice Residency Program at Marquette General Hospital in Marquette, Mich. He thanks Cindy Olson and Kristin Elliott, MD, for their help on this article.
Conflicts of interest: none reported.
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1. CMS Manual System. Pub. 100–04 Medicare claims processing. Dec. 22, 2004. Available at: http://www.cms.hhs.gov/manuals/pm_trans/R417CP.pdf. Accessed March 15, 2005.
2. U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136:760–764.
3. Kenny RA, Rubenstein LZ, Martin FC, et al. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49:664–672.
4. U.S. Preventive Services Task Force. Screening for hearing impairment. In: Guide to clinical preventive services: a report of the U.S. Preventive Services Task Force. 2nd ed. Baltimore: Williams & Wilkins; 1996:393–405.
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