Home Forums Discussions General Discussion Wellness question Redux

Sorry for this. The original post was done in Word, but I can't cut and paste.

This is going to be long. I'd appreciate the views n how other PCP's practice. I am approaching this issue totally ignoring pay for performance, quality measurements or factors other than trying to practice good medicine and getting reimbursed without artificial incentives.

Our practice is all adult medicine, pretty much 100% with more than one chronic medical issue. For years I have been struggling with the concept of the "Wellness Exam." It has not been a big issue previously since most of the insurances we deal with did not pay for an exam done for no specific problem., and the annual comprehensive exam to review all medical issues served as an adequate opportunity to review vaccinations, refill prescriptions and address preventive health issues. We were told by managers of the few companies that did cover "wellness" that we specifically could not offer any treatment, diagnostic testing, or write prescriptions at a wellness visit (although I did stretch this often.)

Now, of course, with Obamacare things are changing as to coverage, and I foresee a lot more people wanting to get everything done under their "free annual exam." Also, we recently did a review of the USPSTF recommendations, and clearly they are mushrooming at a logarithmic rate. Certainly, they have gone beyond what I can hope to cover in a one hour time slot while addressing several chronic medical conditions. So, maybe the time has come to rethink what to do with this wellness exam and how to use it in our practice as a separate visit from an annual reevaluation. But this brings up a lot of potential problems.

1. I can foresee a LOT of pushback if someone comes in for an annual wellness exam , spends the entire session going over preventive health issues, then is told they will need to make to return for another comprehensive exam to actually deal with their medical issues. However, all the actual medical decision making would be taking place outside of this "wellness" setting and of course is where most of the medically useful energy belongs.

2) What about the physical exam? It is not that useful in the first place, and It seems ridiculous to do two complete physical exams in a brief period of time, yet this seems necessary for reimbursement.

3) It seems most efficient to do a wellness exam first to arrange for screening labs, etc. and then have the patient return to discuss actual medical issues and get refills. If done in the other order, there is no incentive for the patient to return for the preventive health portion, in which case I would not have addressed these factors. However, I can imagine the howls of outrage from a patient who has taken time off work for an annual appointment who is told he or she has to make another appointment to get refills, etc. as we did not address any of their actual medical issues.

4) It is tempting to have a medical assistant do the preventive services checklist ahead of time, but I think there is too much medical decision making necessary. Example: is low dose CT chest screening at age 50 or 55 for a smoker who quit 8 years ago with a 20 pack year history? Recommendations are in conflict. Who must NOT get a live virus vaccine?


So, in summary, how are you all dealing with this?

David,

I think the solution(s) is likely regional, so different solutions for different styles of practice and areas of country.

From a pure business perspective, continuing to see Medicare patients has made sense for me. Especially this time of year using the G0402 (welcome to medicare), G0438 (medicare first visit after welcome to medicare), G0439 (medicare annual wellness subsequent visit after first visit), tied with a modifier to a 99213, will do several things. The medicare patient will have no out of pocket expenditure for the annual wellness, and when tied with a modifier and 99213 very little comes out of pocket, and you can justify doing the annual and chronic management in one visit, get reimbursed and make use of every one's time efficiently.

However, if ever audited, one has to make sure the up and go test, vision screening, medicare wellness questionnaire, and end of life issues discussions were done and documented. I allot 45 minutes and have the process streamlined.

I can do the annual wellness and modifier with a 99212 or 99213 with younger healthier patients, and usually get little negative feedback. Once in awhile some on will need to be educated, and sometimes brought in once for the annual and then another visit for the management of chronic disease.

This time of year, especially in the Medicare patient sect, the first 2-3 month lull in payments because of deductibles not being met yet, is dampered by getting the medicare reimbursement for the annuals.

This is how I have modified my practice to the changing environs.

Personally, the reimbursement on Medicare patients handled this way, makes sense for me to continue seeing the ones I have.

I feel like my charges represent what I actually do at time of visit, and seeing 12-15 patients per day and usually 3-4 annual visits per day works quite well for my practice style.

I realize you have opted out of Medicare, and this solution has a heavy Medicare slant but about 40% of my patients are medicare and on a typical day two thirds are medicare. So at this point opting out for me has not made sense from an economic perspective.

In both medicare and non medicare patients, I will have them come in 3-5 days before their visit for labs, and I do all my own intake for meds, and print up a med list and continuity care record to minimize med errors.

However, like you am interested in how others respond to your question.

Jimmie,
This isn't really a Medicare question any more. Now everyone will have a wellness benefit, and will want to use that as their annual reevaluation exam. You imply you do have people make 2 separate exams. My question is how you educate people to do that? What do you do when someone comes in for their "free" exam expecting their problems to be addressed?

David,

You are right, and I should have been more precise, and by using the Medicare example, I was trying to make the point and not very well, the Medicare annual wellness model reimbursed by Medicare with no out of pocket expense, will be similar to the newer model with the Coop/exchanges, I think.

I have material hanging up in the exam rooms and by my nurses station that explain what is involved in an annual exam and the difference between the f/u chronic management exam. Often time I will or my nurse will educate during intake, more so when I started this with medicare annual exams three years ago.

For those patients I sense resistance to this concept or have had issues/complaints about the annual tied in with a modifier, I offer to have them come in at two separate times to do just annual and the chronic exams, but most decline, because they see the waste of time involved in this.

My nurse, in house billers and I, have made an effort over the past 3 years educating about this process and that in essence during one exam I am doing two, the annual and chronic problem followup.

It takes awhile to adapt but most of my patients have, and I think all parties involved are reasonably satisfied with this approach.

Do I understand correctly that you bill for separate services on the same day? I didn't think you could do that.

Yes I bill for an annual and also a 99213(2) with a 25 modifier, in both medicare and non medicare patient populations, and get appropriately reimbursed. This may be a regional issue, but I had a partner start doing this over a decade ago, but I did not start until medicare started paying for annual wellness exams about 3-4 years ago.

I have been reviewed by the medicare auditors that come to office and have never had an issue. The reimbursement on medicare is close to what a straight annual private without a modifier is.

Generally the older more complex patient is billed this way but occasionally I will have a medicare patient on no meds or problems, and then do not use a modifier just the annual exam charge. As the age decreases the higher percentage of just the annuals without modifiers will increase.

I have just learned to bill based on what I do and document, and deal with any fall out such as irate patients, but those are few and far between.

Jimmie,
How do you document on this? Do you do 2 separate notes; one for the wellness and one for the problem based? We have on occasion, billed this way and some payors pay us appropriately, while others cut us to the quick when we do this (Aetna for sure!).
Thanks,
Amber

Amber,

I could have you chat with our office manager, and she could tell you a bit more detail about rejections, but off hand I cannot think of any problematic ones. Reimbursement rates are fine.

I do one note on all patients whether just an annual or annual with 25 modifier so for instance a typical medicare patient with diabetes, hypertension and hypercholesterolemia will be treated as follows.

He will have a portal, hopefully, fill out his medicare wellness survey on his computer and send in before visit or fill out at visit during intake. (working on getting more to fill out on computer). He will have had his labs drawn, sent to his portal 3-5 days before visit, looked up results and compared to last years results.

He checks in and my nurse will do up and go test, vision screening and disuss the POLST form. I print out a med list and continuity care document, BP's and weights graphed out and any pertinent change in labs, then go into exam room.

Do my thing go over PMHx, meds, all social family ROS preventative stuff, exam and get a list of other docs.

I can generally get through everything and with templates and dragon have my note done, everything billed, with the quick billing in AC and print up super bill and have summary sent to smart phone or computer as they are driving home.

AC/Updox has been a tremendous tool to make this encounter satisfactory for most patients, as I can spend most time looking them in the eye and listening, as I take notes on a printed up previous note with all their pertinent history in the exam room as well. Will send any e-orders to my nurse, e-scripts, or educational material on my in exam room printers by using my chromebook remoted to my "terminal server".

David,

I need to make a correction above, I meant to say medicare reviewers not auditors. The ones that come in office and review records to make sure the documentation is there to justify the charges submitted.

Also just a few observations. I rarely get any complaints from medicare patients when they receive my office charges for an annual with modifier and 99213. However the 55-64 year old who may have to pay out of pocket, often times the preventative charge is covered and they have to pay out of pocket for a portion of the 99212 or 99213, seems to occur more often compared to the medicare group.

So with ongoing education about what is entailed in an annual versus management of chronic conditions, and how they will be billed, has been helpful to reduce these situations.

We recently met with the head honcho of the Montana exchange/COOP program being instituted, and I am still trying to get up to speed with the platinum, gold, silver and bronze plans, but I think the mindset of patients in these programs will be more akin to the medicare group. I have a feeling there will be less documentation required than with a medicare patient, and less complaints with charges as it occurs in the private sector group currently. I hope any way.
Sorry this is very long winded, but I am likely to participate with the exchange/COOP, and think from a provider perspective, may be a good thing for a small primary care office.

Jimmie,

If that works more broadly than Medicare, it may be the answer. Our closest analogy is a patient who wants an annual comprehensive exam done and either a flight physical or CDL medical at the same time. Since neither of those services is paid for by insurance, we charge an "add-on" fee that is billed directly to the patient, not using a CPT code at all. My concern from your description, however, is that with the blossoming of preventive health requirements and the complexity of many of our patients, adding a 99213 won't come very close to covering the total time spent r work done. I'll have to think about this more. Thanks for the input.

David,

One additional thought, and I do not recall the code #, but on occasion I have used the extended visit charge. I have not done this with the annual, 99213, modifier combination, but with a 99214 that takes more than the designated time. I am away from the office, but can let you know which code #, but this worked without a problem in the past. However, if tied in with an annual, 25 modifier and 99214, I do not know if that would pass muster or not.

I think some of the complexity of care, we just take in the shorts, but I am open to ways of capturing the work we do so we can get the best reimbursement. Also I have a partner that does flight physicals, and I will see if he has any ideas.

My flight physical reply was just by way of analogy, Jimmie, not a further question as to how to deal with that issue specifically. My focus remains on the increased complexity of wellness vs. comprehensive care. Thanks for all the help.

David,

Anytime, and please forgive the effusive, convoluted manner in which I dealt with your question.

Our state health CO-OP was awarded 58 million federal dollars to get up and running. Reimbursement for providers will be equivalent to the Blues, and preventative services will be 100% covered and 25 dollar copay for primary care charges for doctor visits (not preventative care) in the Gold plan.

So I agree your question will continue to become ever more significant, and education about distinguishing wellness vs. comprehensive care will continue to be ever important.

Jimmie,
Have you ever used the extended visit code with a wellness exam code?
In terms of office management, I realize that when we schedule a comp exam with the FAA or CDL add-on, we schedule an hour and a half, to allow time for filling out forms and the extra MA duties involved like audiogram, vision, U/A, etc. As long as we can recoup the charges with the Wellness/annual exam in a similar fashion as you suggest, I have no problems in doing that in that setting as well. I just want to be able to take my time, feel I'm being thorough, and not feel abused.

David,

I have not, but I will ask Dr Mel if he has. His notes/management of a patient are textbook thorough. I think he uses the extended visit code more than I.

David,

Just a followup note. I checked with my office manager, and the extended visit with and annual visit is not being done currently, and she thought there may be a higher likelihood of rejections, but I do not have any experience with this combination to know for sure.

However, I double checked with my office manager and she cannot recall any rejections with medicare or privates when doing annual with 99212 or 99213 with a modifier, and I do not use the 99214 code much at all with an annual, but have not had any rejections when I did.

Thanks so much, Jimmie. We are in the process of trying to sort all of this out and make a coherent plan that will work for us. I greatly appreciate your insights.

Jimmie,

We started to do the Medicare AWV(annual wellness visit) few months ago. we have been able to definitely bill for evaluation and management (E&M)(99212-99215) with the modifier 25 and the wellness visit on the same day. As you, we use the AC templates for most the info that goes with the AWV in the same E&M note. Since most our patients are not tech savvy, we do everything when the patient arrives.
A few comments / questions:
I have not found that end of life discussions are part of the AWV. Where did you find this?
I have to say that some of the CMS requirements of the evaluation are vague and can be done in different ways.
For instance, I am assuming that the up and go test is part of your review of functional ability.
What do you use for detection of cognitive impairment ? We use the mini-Cog.
What do you use for screening of status of Depression? We use the PHQ-2 followed by the PHQ-9 if necessary.

Thanks for your posting and comments.

Romel

So how does this work out financially for you? Does a wellness plus, say, a 99214-25 do better than just a straight 99215?

David,

It looks like it will, we just started 2 months ago and already seen the payments.
Basically, You are providing two different services in one day.
You document and bill your E&M as you usually do, this reimbursement is subject to deductible and coinsurance.
Of course, It will take you some extra time to collect and put in order the documentation to justify the AWV billing. You will need to get familiar with the requirements and see how much it will take you to do it. It could easily take extra 15-30 min depending of the complexity of the patient.
Here in NJ, G0438 (initial AWV, paid once a lifetime)pays $188 and the G0439 (subsequent AWV) pays around $ 126. This payments are not subjected to deductible of coinsurance.
Look into this website for guidance
http://www.capturebilling.com/medicare-g0438-g0439-two-new-annual-wellness-visit-codes/

Romel,

I will include a checklist from the ACP about the annual wellness visit, and with this check off list advanced directives is included.
chrome-extension://bpmcpldpdmajfigpchkicefoigmkfalc/views/app.html

I have my nurse do the actual up and go test. She times the amount of time it takes the patient to walk 10 feet from a sitted position, turn around and resume the sitting position. So this is part of the review for functional ability.

The depression and cognitive issues are screened for in my annual wellness questionnaire and if abnormal will f/u on. Also if the timed up and go test is prolonged, I have a handout regarding fall risk that is printed up and discussed.

Romel,

Thank you as well for your post and comments and just realized the above link did not work, but if you scroll near bottom of article on this link and click on check list, this will show about end of life discussion. But you are right some of this stuff is vague and I think a multifaceted approach is quite acceptable.

http://www.acponline.org/running_practice/payment_coding/medicare/annual_wellness_visit.htm