Medicare Wellness and Care Coordination Services
Providing Medicare wellness and care coordination services such as annual wellness visits, chronic care management, advance care planning, and transitional care management allow your practice to:
- Optimize fee-for-service revenue
- Improve quality
- Decrease total cost of care.
These services may also help financially support other population health management initiatives.
Annual Wellness Visits (AWV) -- The AWV offers an opportunity for a patient to partner with their physician to focus on preventive screening and wellness. The creation of a personalized prevention plan created for the beneficiary is a way to improve patient engagement.
Medicare Care Coordination
Chronic Care Management (CCM) -- Family physicians and other eligible health care professionals can be reimbursed by CMS for providing CCM services to their Medicare patients who have two or more chronic conditions that are expected to last at least 12 months.
Transitional Care Management (TCM) -- Two CPT codes are used to report TCM services and are designed to pay for services provided to Medicare beneficiaries whose medical and/or psychosocial problems require moderate- or high-complexity medical decision making during transitions in care from a hospital or other health care facility to a community setting (e.g., home, rest home, assisted living).
Advance Care Planning (ACP) -- ACP is the face-to-face time a physician or other qualified health care professional spends with a patient, family member, or surrogate to explain and discuss advance directives. Two CPT codes are used to report ACP services: 99497 and 99498.
Side-by-Side Comparison of Medicare Wellness and Care Coordination Services
|Financial Importance: AWV||CCM||ACP||TCM |
|Financial Importance: Initial Preventive Physical Exam (IPPE) G0402 - $169* |
Initial AWV G0438 - $175*
G0439 - $119*
Supports patient assessment, patient-directed goal setting, and development of a comprehensive care plan.
The AWV is 100% covered—no copay nor deductible for eligible beneficiaries
Monthly payment opportunity
Initiating chronic care by a comprehensive assessment and care planning by physician or ARNP/PA during office visit, AWV, or when CCM is initiated. Requires the development of a care plan by the practitioner.
This may only be billed once.
|CPT code 99497 - $86*|
First 30 minutes (minimum 16)
CPT code 99498 - $76*
Add-on for additional 30 minutes
Opportunity to discuss patient and caregivers’ wishes concerning end-of-life care
No copay for Medicare beneficiaries if done during AWV
|CPT code 99495 - $167* |
Moderate to high complexity
CPT code 99496 - $236*
Sets up a safe and successful patient transition from a hospital or other health care facility to a community setting
|Operational Advantages: AWV||CCM||ACP||TCM|
|Operational Advantages: AWV helps with empanelment and attribution of Medicare beneficiaries|
Establishes or strengthens rapport with the patient and/or caregiver
Chance to introduce TCM, CCM, and ACP to the patient
|Reduces telephone calls to the practice by developing a regular communication channel for CCM patients|
Regular monthly payment will support additional clinical staff hours or positions
Time for staff to provide patient education and answer medical questions
|No limit on the number of times ACP can be billed for a given beneficiary during a given time period|
Opportunity for patient to communicate and/or document wishes for family
Increased patient engagement and satisfaction in their care
|Increases patient satisfaction by reducing risk of readmission by improving care and meeting patient’s needs|
Service requires face-to-face visits with primary care provider and team in 14 days for moderate complexity (99496) or 7 days for high complexity (99495)
Prompt follow up decreases unnecessary readmissions and reduces total cost
|Clinical Outcomes: AWV||CCM||ACP||TCM|
|Clinical Outcomes: Improves quality of care by identifying and closing care gaps and developing a care plan|
Provides overall assessment and plans personalized preventive needs and early interventions
Opportunity to update the clinical record to reflect current problem list and diagnosis coding for hierarchal condition category (HCC) risk scoring and risk stratification
Planning access to needed care will decrease emergency room visits and hospitalizations and drive down cost
|Decreased hospitalizations/emergency room (ER) visits will decrease cost of care through prevention and early intervention|
Improved follow through and implementation of personalized care plan Increasing dedicated staff time will close care gaps
Improves communication and care coordination across health care professionals and settings
Improves patient engagement and accountability with regular communication with care team
Decisions on end-of-life care are documented in the medical record
|Improved continuity of care through:|
Medicine reconciliation and answering beneficiary/caregiver questions to support safe and successful transitions
Review of hospital and pending diagnostic tests/treatments ordered
Improved coordination across the medical community
Establishing or reestablishing referrals with community providers/services to support patient’s behavioral health or health-related social needs
* Medicare and Medicare Advantage payment varies by geographical location. Check with your local Medicare Administrative Contractor (MAC) or plan for local/contracted rates. Values from Medicare Physician Fee Schedule 2018.
** Many Medicare Advantage plans will not pay for Chronic Care Management separately as monthly care management support includes this service.
Different Approaches to Help Your Practice Get Started
Annual Wellness Visits
- AWV can be provided to all Medicare Part B patients
- Use this service to identify patients who would benefit from a discussion regarding their self-management goals
- Choose those patients which the staff has identified as highest risk (staff are concerned that the patient is unstable or may be more likely to need additional services or have recently been to the ER)
- Use this service to risk stratify your patient population
- Use this service to document diagnoses and conditions to accurately reflect patient severity of illness (HCC) and risk of high-cost care
Chronic Care Management
- Identify Medicare Part B patient with at least two or more chronic conditions expected to last 12 months or until the death of the patient
- Prioritize patients at highest risk of hospitalization or have recently been/are regularly seen in the ER
- Start with patients that regularly call into the clinic to manage symptoms or with medical questions
- Identify patients that may be mostly likely to benefit from care management based on the number of specialists involved in their care or who have limited social or local family support
- Identify patients dual eligible for traditional Medicare and Medicaid (not managed Medicaid), or with secondary insurance coverage
- Identify volume needed to hire additional part-time or full-time staff and then prioritize eligible patients
Advance Care Planning
- Identify patients and families in which you have a strong rapport
- Start with patients scheduled for AWV (no patient copay if offered with AWV)
Transitional Care Management
- Identify hospitals and emergency departments (EDs) responsible for the majority of patients’ hospitalizations. With the shared goal of decreased readmissions, develop a relationship with those hospitals to improve timeliness of notification so the practice can reach out to patients within two working days of discharge
- Add this service to decrease cost of care by reducing unnecessary readmissions
- Add this service after AWV and CCM as the volume and associated revenue of this service is hard to anticipate