In two previous articles, I explained the elements required for the new Medicare annual wellness visit (AWV).1,2 In this article, I share ideas and emerging best practices for providing the components of the AWV in a way that most benefits your patients while protecting your practice from loss of income and productivity. From educating patients about what to expect at a wellness visit to planning the delivery of the related services, there are opportunities to make the most of the AWV for patients and your practice.
Manage patient expectations
Although the AWV has been referred to as a “physical” in ads encouraging Medicare beneficiaries to take advantage of this new benefit, a head-to-toe exam is not required. Patients may also expect to receive diagnosis and management of problems at this encounter without charge. To set the right expectations and give patients fair warning of additional expenses they may incur, a simple one-page letter may be effective.
SAMPLE LETTER: A WORD TO OUR PATIENTS ABOUT MEDICARE AND WELLNESS CARE
We want you to receive wellness care – health care that may lower your risk of illness or injury. Medicare pays for some wellness care, but it does not pay for all the wellness care you might need. We want you to know about your Medicare benefits and how we can help you get the most from them.
The term “physical” is often used to describe wellness care. But Medicare does not pay for a traditional, head-to-toe physical. Medicare does pay for a wellness visit once a year to identify health risks and help you to reduce them. At your wellness visit, our health care team will take a complete health history and provide several other services:
Screenings to detect depression, risk for falling and other problems,
A limited physical exam to check your blood pressure, weight, vision and other things depending on your age, gender and level of activity,
Recommendations for other wellness services and healthy lifestyle changes.
Before your appointment, our staff will ask you some questions about your health and may ask you to fill out a form.
A wellness visit does not deal with new or existing health problems. That would be a separate service and requires a longer appointment. Please let our scheduling staff know if you need the doctor's help with a health problem, a medication refill or something else. We may need to schedule a separate appointment. A separate charge applies to these services, whether provided on the same date or a different date than the wellness visit.
We hope to help you get the most from your Medicare wellness benefits. Please contact us with any questions.
Develop scheduling protocols
Since the AWV has a lot of components, it may take generous amounts of both staff and physician resources to provide the service. Taking some time to determine how these appointments best fit into your existing schedule and to create a scheduling protocol should save more time and frustration later. For example, do you want to schedule these appointments on certain days of the week, in the morning with patients fasting in anticipation of lab testing, or after specified tests have been ordered and results charted? You should also consider whether you will schedule both an AWV and a problem-oriented evaluation and management service for the same appointment and advise staff on how to address this issue with patients.
Do pre-visit planning
Your staff will need to verify up front not only the patient's Medicare Part B effective date but also whether the patient has received an AWV from any physician in the last 11 months. Otherwise, your service may be denied, leaving the patient with an unexpected bill.
The same verification will be needed for other preventive services that you might advise patients to receive in conjunction with the AWV. It may be ideal to have staff note the last date of these preventive services on an AWV documentation form in advance of the visit. This information can be obtained in several ways. A chart review or phone interview could be conducted soon after the visit is scheduled to gather a pre-visit history. More reliably for purposes of payment, staff could use an electronic insurance inquiry or Internet eligibility service to verify eligibility for preventive services. Whatever the approach, having this information before the visit will help you to determine which preventive services are needed and whether the patient is eligible to have these paid for by Medicare.
A pre-visit history can also identify whether the patient needs tests such as the cardiovascular and diabetes screening blood tests, which should be completed prior to the AWV to allow discussion of the results at the encounter. Additional considerations might include whether the patient should be instructed to not eat before the visit and whether occult blood test cards should be provided before the visit with instructions for the patient to return the cards at his or her appointment (since compliance with this test is low, you might ask that the patient bring the cards to the visit, whether completed or not).
Define the encounter
It is important to work through the required elements of the AWV, define each step, determine which staff will perform each step and identify any tools or resources needed. The annual wellness visit encounter form published in the January/February 2011 issue of FPM is a useful reference for this purpose.
History. To begin with, you'll have an extensive patient history and medication list to complete. Do you want to send a form to the patient for completion prior to the visit, conduct phone interviews prior to the visit, or have ancillary staff gather this information when the patient arrives for the appointment? However you approach it, this information can be documented and ready for you to review with the patient when you enter the exam room.
Screening for depression, functional ability and safety. Depending on the scope of practice and skill levels of your staff, the depression screening and the functional ability and safety screening may also be conducted by ancillary staff in advance of your visit with the patient.
Cognitive assessment. The assessment that the Centers for Medicare & Medicaid Services (CMS) envisioned when establishing the AWV requirements will be based on your interactions with the patient and input from family members or other caregivers present during the encounter. Gathering impressions from the staff who obtained the patient history or performed other elements of the encounter may also be beneficial. Documentation should include evidence of assessment, such as notations of the patient's general appearance, affect, speech, memory and motor skills. You may also wish to use an instrument such as the Mini-Cog, the Montreal Cognitive Assessment or the Mini-Mental State Exam.
Screening for hearing and vision loss. This component may be met by questioning the patient or caregiver about the patient's hearing. You may wish to conduct the whisper test. A visual acuity test should also be performed.
The remainder of the physical exam. Medicare regulations do not set forth requirements for other aspects of the physical exam. These are for you to determine based on the patient's age, gender, level of physical activity, last exam and known medical conditions. One decision you will have to make is whether to perform the clinical breast and pelvic exam at the same encounter as the AWV. They are separately defined Medicare benefits, but at least one Medicare contractor has said that, if both services are provided at the same encounter, the fee for performing the breast and pelvic exam should be carved out of the fee for the AWV (equivalent to not charging for the breast and pelvic exam but reporting it). You may wish to clarify this with your Medicare contractor up front.
Plan for efficient follow-up care
Patient risks and problems identified through the history, screening and exam must be addressed by continuing interventions already in place, ordering further screening or recommending new interventions. Your documentation should reflect your discussions of the risks and benefits of each of these. Referrals to other providers and community services should be documented as appropriate. A preventive service plan for the next five to 10 years should be developed, and a screening plan or checklist should be provided to the patient following the visit. Discussing advance directives or surrogate decision makers may also be appropriate but is not required.
You and your staff can save significant time by establishing protocols for responding to positive screening results and identifying resources you'll use for follow-up. You'll want to consider questions like these:
If a patient gives a positive response to both questions in the simple depression screening, will you be prepared to conduct further screening such as PHQ-9? If depression is diagnosed, how will you address it?
If a patient has been recently injured in a fall or has other indications of impaired functional ability or safety hazards in his or her home, how will these be addressed?
Can you implement standing orders for influenza and pneumococcal vaccinations?
Will your practice provide brief behavioral health, medical nutritional and perhaps even minimal physical therapy services as part of the AWV? If you don't offer these services, are you prepared to make referrals? Note that although Medicare contractors still pay separately for these services, it is likely that these codes will soon be bundled with codes for the AWV. If your practice includes licensed professionals who provide these services, you may wish to bring the patient back on a different date to continue this care.
What patient handouts may be most helpful, and where will you find them?
What community services would benefit your patients (for example, meals and transportation services for the elderly), and can you share this information easily?
You likely have many of these resources already, and the resource list below includes links to additional screening tests, tools and information that can facilitate AWV care. If staff are trained in your practice protocols and can easily access information at the encounter, care management and coordination will be easier. See “The annual wellness visit: Putting it all together” for a vignette that describes an efficient annual wellness visit.
THE ANNUAL WELLNESS VISIT: PUTTING IT ALL TOGETHER
Jim Smith calls his doctor's office to ask about the free Medicare physical he's heard about. Sally at the scheduling desk explains that an annual wellness visit (AWV) is paid in full by Medicare but that there may be other charges if the doctor addresses problems or orders certain testing. She checks the effective date of Part B coverage on the file copy of Mr. Smith's Medicare card noting that he is eligible for the AWV. Mr. Smith accepts an appointment with Dr. Williams for a time designated for preventive visits. Sally mails Mr. Smith information on what to expect and what to bring to the visit and history forms for him to complete and return.
Ann in the billing office verifies Mr. Smith's eligibility using the Medicare contractor's online system. She confirms the effective date, deductible remaining and next eligibility dates for covered preventive services. She forwards these details to Kelly, the LPN who will develop a pre-visit plan.
Before Mr. Smith's visit, Kelly calls him to verify his appointment, discuss his expectations and provide information. Kelly explains that the Medicare eligibility records indicate he has not received a pneumococcal vaccination but did receive an influenza vaccination several months ago. She also asks whether he has received the herpes zoster vaccine covered under Medicare Part D. Kelly explains Dr. Williams' recommendation and the importance of these vaccines. Mr. Smith agrees, so Kelly plans for doses to be available at the visit pending verification of the herpes zoster vaccination coverage. Kelly asks if he wishes to address specific medical concerns at this visit. He asks if he can get refills on the GERD medication prescribed two months ago, noting it has had good results. Kelly makes a note to ask Dr. Williams.
Kelly meets briefly with Dr. Williams on the morning of Dr. Smith's visit to review the day's visits. Dr. Williams confirms that the vaccines should be given and approves the refill.
When Mr. Smith arrives for his appointment, Sally greets him and asks for the completed history forms, which she scans into the electronic health record (EHR) system.
Kelly escorts Mr. Smith to an exam room where she reviews his history, adding this and further information to the EHR's AWV template. She also reviews each medication with Mr. Smith, noting whether he is taking each as prescribed.
She then inquires about falls in the past year, noting none but discussing safety features. Mr. Smith notes that a home health agency that cared for his wife provided a safety checklist last year and he did install rails in the bathroom.
Next Kelly obtains and notes measurements including blood pressure, height, weight, BMI, pulse and respiration. She proceeds with a simple two-question depression screening, which is negative. She conducts a simple gait assessment in the hall and documents the results. She also asks Mr. Smith to read an eye chart posted in the hall and documents this as well. She asks about his last eye appointment. He has not had one for several years because new glasses seemed unaffordable. Kelly offers a patient handout that lists vision center discounts for AARP and AAA members.
Kelly confirms that Mr. Smith still wishes to receive vaccinations. She reviews the vaccine information sheets with Mr. Smith and informs him about his Part D plan's coverage of the herpes zoster vaccine. She then administers the vaccines and records them in the EHR.
Dr. Williams reviews Kelly's notes and Mr. Smith's lists of medications and other health care providers. He asks Mr. Smith's reason for taking a garlic supplement and then discusses the pros and cons with him. Dr. Williams explains the need for vision care to detect changes or early signs of disease, and Mr. Smith agrees to make an appointment soon. Dr. Williams notes a negative response to questions about hearing difficulty and steps behind the patient to whisper, “Can you hear me now?” Mr. Smith clearly hears and chuckles. No one accompanied Mr. Smith to this visit, so Dr. Williams does not get family input but sees no evidence of cognitive deficit; Mr. Smith has normal appearance, evidence of good hygiene and ably counts backwards from 100 by 7s.
Because Mr. Smith was seen just two months earlier and reports no new problems, Dr. Williams only examines his eyes, ears, nose and throat and listens to his heart and lungs.
Having completed the history, screenings and exam, Dr. Williams turns to discussions of health risks, current interventions and recommendations. Mr. Smith's BMI indicates that exercise and dietary changes are recommended. They discuss these, and Dr. Williams provides a patient handout on strengthening and balance exercises that they discuss.
Dr. Williams reminds him to get a flu shot in the fall and notes this on the recommendations list that Mr. Smith will take with him. Kelly previously noted the dates of Mr. Smith's last PSA test, colonoscopy and cholesterol check. Dr. Williams recommends repeating these at intervals that he specifies in his notes. He orders a fasting glucose test to screen for diabetes since Mr. Smith qualifies for this Medicare benefit based on his weight and hypertension.
Mr. Smith indicates understanding of the prevention plan and other materials provided during the visit, so Dr. Williams thanks him for coming in and then asks Kelly to schedule Mr. Smith's fasting glucose test. Kelly schedules the test and assures Mr. Smith that the doctor ordered his prescription refill. He wants to schedule an ophthalmology visit on his own, so she provides information. She shows him to the check-out desk, where he is told there is no charge for today's visit and is reminded to fast prior to his upcoming diabetes screening test.
The final step in providing the AWV is to get paid for all you do. Be sure your documentation is complete and signed. Establish processes to capture ancillary services such as lab testing or vaccines administered. Many have asked what ICD-9 code should be reported, but Medicare has not specified a code. Codes in the V70 series should suffice for the primary diagnosis, with additional codes for problems identified and addressed or any preventive services delivered.
These tips should ease the delivery of the AWV. If you have tips of your own, please share them with FPM. With some preparation and teamwork, this service can be one that is beneficial to both patients and physicians.
Articles on preventive care for older patients
The Geriatric Assessment (AFP)
Weight loss and exercise
Soapnote online calculators (with printable results)http://www.soapnote.org/mental-health/folstein-mini-mental-status-exam/ and http://www.soapnote.org/elder-care/mini-cog-screen-for-dementia/
Depression screening and treatment
Depression: What You Should Know (AFP patient handout)
PHQ-9 depression screening tool
Preventive service recommendations
Referrals to other providers and resources