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The Medicare Wellness Exam MARC PRICE, DO FAMILY MEDICINE OF MALTA, PHYSICIAN OWNER NYSAFP TREASURER AND ADVOCACY CHAIR Overview The History behind the Medicare Wellness Exams What are the Medicare Wellness Exams What is covered by the Medicare Wellness Exams How to code for the Medicare Wellness Exams The History 3/23/10 - The Patient Protection and Affordable Care Act Amended 3/30/10 – Health Care And Education Reconciliation Act Goal To end some of the worst abuses by the insurance industry and to award Americans new rights and benefits 4 Year roll implementation The Medicare Wellness Exams In the words of CMS: “CMS is committed to promoting the appropriate use of Medicare preventive services. Medicare now covers a broad range of services to prevent disease, detect disease early when it is most treatable and curable, and manage disease so that complications can be avoided…” “…CMS recognizes the crucial role that health care providers play in providing and educating Medicare beneficiaries about potentially life-saving preventive and services and screenings.” What is Covered Preventive services Initial Preventive Physical Exam (IPPE) AKA Welcome to Medicare Preventive Physical Annual Wellness Visit (AWV) Screenings Vaccinations Behavior therapy and counseling Welcome to Medicare (IPPE) Once in a lifetime Within 12 months of initiation of Medicare Part B coverage Copay/Coinsurance: No Elements History Medical and social history Screening for depression/mood disorders Functional ability and safety evaluation Examination Assessment for end-of-life planning Counseling and Education Including a written plan Annual Wellness Visit (AWV) Initial visit vs Subsequent visit Not within 12 months of starting benefits or last IPPE/AWV Copay/Coinsurance: No Elements History Same as IPPE Examination Same as IPPE, but no mention of end-of-life planning List of current healthcare providers and suppliers Counseling and Education Written screening schedules, interventions and health advice Referrals to health education or preventive counseling services IPPE and AWV Clarifications “Preventive wellness visits” are not annual physical exams Can be performed by a qualified health professional Although specific labs/tests are not included in the IPPE or AWV, tests may be ordered resulting from the exam One-time AAA screening only covered if ordered during an IPPE, not an AWV IPPE and AWV Clarifications A diagnosis code is required, but not a specific one Confirm an IPPE or AWV hasn’t been performed within the past 12 months Separate E/M and medically necessary services can be billed at the same time as the IPPE or AWV with modifier -25 Screening EKG IPPE only Copay/Coinsurance: Yes Ultrasound for AAA IPPE only and if meets certain criteria Copay/Coinsurance: No Cardiovascular Screening - Lipids Every 5 years Copay/Coinsurance: No Screening Diabetes – fasting/non-fasting glucose/GTT Non-diabetics meeting criteria 1-2 times per year depending on previous results Copay/Coinsurance: No Glaucoma Annually if criteria met Copay/Coinsurance: Yes Bone Mass Measurement Every 2 years if criteria met (sooner if medically necessary) Copay/Coinsurance: No Screening Colorectal Cancer – several options Age > 50 yo, timing varies depending on test and risk factors Copay/Coinsurance: No Prostate – DRE/PSA Annually beginning the day after 50th birthday Copay/Coinsurance: PSA – No/ DRE – Yes Depression Annually Copay/Coinsurance: No Screening Pap Tests Annually if certain criteria met, otherwise every 2 years Copay/Coinsurance: No Pelvic Exams Annually if certain criteria met, otherwise every 2 years Copay/Coinsurance: No Mammography Female 35-39 yo - one baseline, >40 yo – annually Copay/Coinsurance: No Screening Alcohol Misuse Annual screening Copay/Coinsurance: No Sexually Transmitted Infections Women – GC/Chlamydia/Syphilis/Hepatitis B Men – Syphilis only Annually for increased risk, 1-3 times per pregnancy (dz dependant) Annually for increased risk Copay/Coinsurance: No HIV Annually for high risk patients, 3 times per pregnancy Copay/Coinsurance: No Vaccinations Seasonal Influenza Once per season, more if medically necessary Copay/Coinsurance: No Pneumonia Once in a lifetime, more if medically necessary and > 5 yrs since last Copay/Coinsurance: No Hepatitis B Scheduled dosing if at high or intermediate risk Copay/Coinsurance: No Vaccinations Those NOT covered under Medicare Part B Zoster Vaccine TDaP Though covered under Medicare Part D (medications) Counseling Diabetes Self-Management Training Individual or group; 10 hrs 1st year, 2 hrs subsequent years Copay/Coinsurance: Yes Medical Nutrition Therapy Individual or group; 3 hrs 1st year, 2 hrs subsequent years Diabetes, renal disease/kidney transplant within 3 yrs Copay/Coinsurance: No Intensive Behavioral Therapy for CV Disease Individual; Annually Copay/Coinsurance: No Counseling Intensive Behavioral Therapy for Obesity Individual; Multiple visits over 6-12 months Copay/Coinsurance: No Tobacco Use Two cessation attempts per year; up to 4 sessions per attempt Copay/Coinsurance: No Alcohol Misuse (Not Dependence) Individual; Four visits per year Copay/Coinsurance: No Sexually Transmitted Infection Prevention Individual; Twice per year Copay/Coinsurance: No How To Code How To Code How To Code How To Code How To Code How To Code How To Code Resources http://www.cms.gov/Medicare/Prevention/Prevntio nGenInfo http://www.cms.gov/Medicare/Prevention/Prevntio nGenInfo/Downloads/MPS_QuickReferenceChart_1 .pdf http://www.medicare.gov/coverage/preventive-andscreening-services.html http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/PreventiveServices.html Questions? Contact Information Marc Price, D.O. 2388 Route 9, Suite 200, Mechanicville, N.Y. 12118 518-899-5390 [email protected] Twitter: Bald_and_Proud
