Get the Medicare Well Visit Right and Get Paid
When the Centers for Medicare and Medicaid (CMS) began to allow for well visits, they sold the idea as an opportunity for the primary care providers to increase their revenue. Many providers were excited about the idea and began performing these well visits. CMS decided not to use the CPT codes for preventative services. Instead, they created their own codes, and with the codes, new requirements for the well visit.
It is the requirements of the Medicare well visit that have created ambiguity amongst providers.
In the first 12 months of being a Medicare patient, seniors are allowed an initial visit, which is the welcome to Medicare visit for preventative care (G0402). Then there is the annual initial visit for those patients who never took advantage of the welcome to Medicare visit (G0438). After a year they can come back and have a subsequent well visit (G0439). These visits are not necessarily about the exam (although an exam can be a part of it). They are about the overall health assessment of the patient. When done well and documented well, these visits can give the provider a better road map for the care of this patient. The annual well visit (AWV) can be performed by a physician, PA, NP, CNS, or other provider under the direct supervision of a physician.
If you perform electronic eligibility, you can find out if the patient has already had their AWV. There is no copay or deductible for these visits. V70.0 is the diagnosis to use, demonstrating that it is a well visit. If during the course of the AWV a problem is discovered and addressed, an E&M can be appended but documentation must show the two types of visits and clearly demonstrate that there was a need for an E&M service with medical decision making.
It is the elements of the AWV that are often not understood by the provider. In truth, most of the visit, if not all of it can be performed without the patient undressing. The purpose is to assess their health and risks in order to make a plan of treatment or care. The following must be in the documentation to meet CMS requirements per the Medicare Manual of 42 CFR 410.16. These are not suggestions but requirements.
- Collect self-reported information about the patient
- Tailor to and take into account the communication of patient
- Take no more than 20 minutes to complete
- It should address the following:
- Demographic data like age, gender, race, and ethnicity
- Self-Assessment of health status, frailty, and physical functioning
- Psychosocial risks like depression, stress, anger, isolation, pain, fatigue, etc.
- Behavioral risks like tobacco, physical activity, nutrition, alcohol, sexual health, safety in home or in the car
- Activities of daily living (ADL) such as can they dress themselves, can they eat, grooming and ambulation
- Instrumental activities of daily living to ascertain if the patient can shop, prepare food, use the phone, clean home, wash clothes, take medication, and handle their finances
- With the well visit orders for colonoscopies, EKGs, or labs can also be done. Other services may include bone mass measurements, diabetes screening, glaucoma screening, and ultrasound screening for abdominal aortic aneurysms. Counseling for tobacco cessation (G0436-G0437) is another tool that has been given to the provider along with weight loss prevention.
Until 2012, many of these preventive services were denied to seniors by Medicare. Not only are there preventative services now but also counseling that can help seniors achieve better health. Physicians should not miss out on the financial opportunities that these services provide. As with all things Medicare however, there are rules that must be abided by. It would make sense from a practical point of view, to create a well visit template that would walk you through the visit to make certain you have met all the requirements for Medicare.
If you use Kareo EHR, a well visit template is available already. If you don't use an EHR or you are looking for a new EHR that provides tools designed for practices like yours, register for the next Kareo EHR demo.