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Monday Feb 05, 2018

Done Right, Annual Wellness Visit Helps Patient and Practice

Editor's note: This is an abridged version of an article originally published in the January-March 2018 issue of Missouri Family Physician.(issuu.com)  

[femalw physician talking with elderly male patient]

As family physicians, we need to revisit the concept of wellness encounters and how we implement them in real-life practice. I realize this is a topic that has had its time in the health care debate and that now most of us simply follow along and do a pretty good job (so we think) of performing wellness visits on a handful of compliant patients who are willing to schedule these every year. There are also others among us who feel that because wellness is something we do all the time during our routine health-maintenance visits, there is no need to schedule separate additional encounters. 

But in this data-driven age of health care, annual wellness visits are an important element of medical practice that must constantly evolve along with the technology we use, such as electronic health records (EHRs).

I first learned about Medicare annual wellness visits (AWVs)(www.cms.gov) while I was in residency back in 2011 shortly after they were introduced by the Patient Protection and Affordable Care Act. I remember thinking it odd that a separate medical visit was being recommended during which patient "wellness" would be addressed. Isn't wellness what physicians address during every medical visit? I wondered if such visits were just another hoop medical professionals needed to jump through to satisfy the bureaucratic demands of our increasingly complex health care system.

To add to my concerns, patients shared concerns that this was primarily a visit to talk about end-of-life planning and to discontinue unnecessary health maintenance initiatives on their way to the morgue. In short, many patients told me that they thought it was a self-serving effort by Medicare to save money.

Although I do think that cost savings and revenue generation are among the benefits provided by AWVs, I have come to see these encounters primarily as extremely beneficial opportunities to focus attention on implementing and tracking health maintenance services. I find that they are relatively straightforward and can be completed in short order without much stress if done correctly. The key is to educate your patients on the purpose and nature of AWVs. Advise them that these are primarily free-to-patient counseling visits during which pertinent info is gathered and updated, meds are reconciled, appropriate screenings are ordered, and needed vaccines are administered. They also need to know that they usually do not include a comprehensive head-to-toe physical exam.

Recently, wellness visits became a central topic of discussion at my clinic in rural southwest Missouri. It became evident through our quality-care tracking that the clinic was not consistently meeting its benchmark number of AWVs. This was shocking to us. We could not understand how it could be possible when we do so much "wellness" and preventive "health maintenance" in our practice. Further investigation revealed that our documentation and coding habits were not always sufficient to allow the medical coders to capture all the types of wellness visits we were actually doing.

This prompted me to do some more research about AWVs to make sure we were meeting the standards and maximizing the potential of these encounters. Unfortunately, the more I investigated, the more I found great uncertainty about what can and can't be documented without generating additional charges for the patient. In general, the consensus seems to be that anything deemed preventive is considered appropriate during a wellness visit. This means that medication refills, vaccines and screenings should not result in the patient receiving unexpected bills. In some cases, it may be necessary to code for chronic diagnoses addressed during the AWV, but patients should be advised that this may generate a charge. That being said, the general rule of thumb should be to stick to preventive codes and avoid procedure codes during AWVs. To play it safe, an additional visit note may be generated to address separate acute/chronic issues and procedures.

I find this to be one of the trickiest parts of the AWV, because I rarely have time to schedule patients for a second encounter during the same day and acute issues often cannot wait. Hence, I have sometimes addressed such issues off a separate nonbillable chart note or documented them in the AWV and let the patient know that this would likely result in added charges. Split billing can be done when you provide a significant, separately identifiable, medically necessary evaluation and management service in addition to the AWV.

As a physician, I especially appreciate the opportunity to promote preventive care to my most vulnerable patients: the aging and aged. One would hope that these yearly visits actually achieve the stated goal of preventing onset of disease and disability by slowing existing illnesses through health promotion and disease detection. AWVs are also intended to help coordinate screening and preventive services that may already be covered under Medicare. For sure, they enhance revenue by increasing relative value units, volume and ancillary services covered by Medicare.

Now that I am in my fourth year of postresidency practice, I feel I am finally in a good rhythm of scheduling and coding AWVs and similar visits, including initial preventive physical exams, well-woman visits and well-child visits.

I am determined to start doing a better job of scheduling annual physicals for young healthy males (18-49 years old); I think it is emblematic of our growing dependence on EHR prompts and health-maintenance trackers that young men with no major wellness goals to monitor may be overlooked and fall through the cracks when it comes to annual preventive care.

Wellness visits are a great opportunity to enhance the quality and consistency of preventive health maintenance for our patients. Effective patient recruitment, education and scheduling, along with appropriate visit documentation and coding, are key to achieving good success with billable annual preventive health maintenance. One must become adept at utilizing and updating the EHR efficiently and meaningfully, and data must be easily retrievable. I can attest that with an open mind and willingness to learn, the EHR can maximize your ability to track and deliver excellent preventive care.

Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri.

Posted at 02:49PM Feb 05, 2018 by Kurt Bravata, M.D.

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