Martin Arron, MD, MBA Brenda Matti-Orozco, MD. CHP-IPA April 16, 17, 18, 2013

Martin Arron, MD, MBA Brenda Matti-Orozco, MD CHP-IPA April 16, 17, 18, 2013

1. Describe the history and scope of Medicare s preventive services 2. Explain differences between the Welcome to Medicare Initial Preventive Physical Examination (IPPE) and the Annual Wellness Visit (AWV) 3. Discuss RN/NP, and LPN/MD models of delivering Medicare preventive visits 4. Review the documentation and billing requirements 5. Present sample documentation and billing templates

Medicare s Path to Prevention No payment may be made under part A or part B [of Medicare] for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of Colorectal illness cancer or injury or to screening improve the functioning of a malformed body 1/1/1997 member 1 Annual prostate cancer screening 1/1/2000 Medicare signed into law 7/30/1965 HBV vaccine 1/1/1984 Influenza vaccine 1/1/1993 Welcome to Medicare Visit 1/1/2005 Annual Wellness Visit 1/1/2011 1965 1971 1977 1983 1989 1995 2001 2007 1/1/1980 Pneumococcal vaccine 1/1/1990 Screening mammography 1/1/1997 Screening Pap / Pelvic 1 Social Security Amendment XVIII, 1965

Medicare offers preventive visits? National survey of 1,208 adults 65 and older Have you heard about the Annual Wellness Visit? DK, 14% Yes, 32% In the past 12 months, have you had your free Annual Wellness Visit? Not sure, 9% Refused, 2% Yes, 17% No, 54% No, 72% John A. Hartford Foundation Public Poll: How Does It Feel? The Older Adult Health Care Experience. April 23, 2012

1 Medicare Physician Fee Schedule Search. Centers for Medicare and Medicaid Services. http://www.cms.gov/apps/physicianfee-schedule/. Accessed 25 Feb. 2013. 2 Medicare Preventive Services National Provider Call: The Initial Preventive Physical Exam and the Annual Wellness Visit. Centers for Medicare and Medicaid Services. 28 March 2012 3 Fiegl, Charles. "Medicare's Missed Checkups: Few Seniors Get Wellness Exam." - Amednews.com. 2 May 2011.

Medicare s Preventive Visits Welcome to Medicare Initial Preventive Exam One time only within 12 months of enrollment Annual Well Visit Personalized Prevention Plan Services Once every 12 months MD, PA, NP, CNS MD, PA, NP, CNS Limited physical exam No physical exam Establish plan of prevention Update preventive care plan No co-pay, co-insurance or deductible No co-pay, co-insurance, or deductible 2 Medicare Preventive Services National Provider Call: The Initial Preventive Physical Exam and the Annual Wellness Visit. Centers for Medicare and Medicaid Services. 28 March 2012

Documentation Requirements Welcome to Medicare Annual Well Visit 1. Health Risk Assessment 2. Medical and Social History 3. Depression Screen 4. Functional Ability and Safety 5. Vital Measurements 6. Focused Physical Exam 7. Create list of risk factors and health conditions 8. Create screening schedule 9. Education and referrals a) EKG (optional) b) AAA ultrasound (optional) c) Advanced Directives (optional) 1. Health Risk Assessment* 2. Medical and Social History* 3. Vital Measurements 4. Risk factors and health conditions* 5. Screening schedule* 6. Education and referrals a) Advanced Directives (optional) * Update original version Medicare Preventive Services National Provider Call: The Initial Preventive Physical Exam and the Annual Wellness Visit. Centers for Medicare and Medicaid Services. 28 March 2012

1. Health Risk Assessment a) Can be administered prior to visit A Checklist for Your Medicare Annual Wellness Visit. Medicare's Annual Wellness Visit. American College of Physicians. Available at http://www.acponline.org/running_practice/payment_coding/medica re/annual_wellness_visit.htm. Accessed on Accessed on 22 Feb. 2013.

2. Establish Medical and Family History 3. Depression screening a) Any appropriate screening test that is recognized by national medical professional groups PHQ-2 1 PHQ-9 2 1 U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136:760 764. 2 Kroenke, K. & Spitzer, R.L. (2002). The PHQ-9: A new depression and diagnostic severity measure. Psychiatric Annals, 32, 509-521.

4. Review of Functional Ability and Safety a) Hearing Impairment 1 1) Do you have difficulty hearing? a. Yes Audiometry b. No Whisper Test b) Ability to successfully perform ADLs 1) Review HRA 1 Bagai A, Thavendiranathan P, Detsky AS. Does this patient have hearing impairment? JAMA. 2006 Jan 25;295(4):416-28.

4. Review of Functional Ability and Safety cont. c) Fall Risk Screening 1 1) 2 falls in past year, p/w fall or gait impairment a. Multi-factorial risk assessment 2) Single fall in past year a. Timed Up and Go test 2 d) Home Safety 3 1) CDC Check for Safety 1 Kenny RA, Rubenstein LZ, Martin FC, et al. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49:664 672. 2 Bohannon RW. Reference values for the timed up and go test: a descriptive metaanalysis. J Geriatr Phys Ther. 2006;29(2):64-8. 3 "Home and Recreational Safety." Centers for Disease Control. Available at http://www.cdc.gov/homeandrecreationalsafety/pubs/english/ booklet_eng_desktop-a.pdf. Accessed on 20 Feb. 2013.

5. Focused Physical Exam a) Height, weight, BMI b) Blood pressure c) Assessment of cognitive function 1) Mini-Cog 1 d) Other areas as deemed appropriate based on medical and family history 1 Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003 Oct;51(10):1451-4.

6. Establish list of risk factors and conditions for which interventions are recommended or underway for beneficiary Blood pressure Diabetes Smoking Stress Safety belt Cholesterol Weight / Nutrition

Preventive Service Frequency Last Done Body Mass Index (BMI) Annually Height Weight Blood Pressure / Every 2 yrs, if BP </= 120/80 mm hg; Annually, if BP >120-139/80-89 mm hg Vision Every 3 yrs up to age 40; Every 2 yrs aged 40+ Abdominal Aortic Aneurysm Once, between the age range of 65-75 and smoked 100+ cigarettes in lifetime Cholesterol Testing Regularly beginning at age 20 with risk factors Diabetes Screening With a sustained BP >/= 135/80 mm Hg Colorectal Cancer Screening Annually, Fecal Occult Blood Stool (FOBS); Every 5 yrs, Sigmoidoscopy with FOBS; Every 10 yrs, Colonoscopy Sexually Transmitted Diseases (STD s) As necessary for those with risk factors Depression Screening As necessary for those with risk factors Alcohol Misuse Screening As necessary for those with risk factors Immunizations: Pneumococcal (Pneumonia) Vaccine Influenza (Flu) Vaccine Other MEN S PREVENTIVE WELLNESS PLAN Patient Name Date Pneumonia: 1-2 doses up to age 64; Pneumonia: 1 dose age 65+ Influenza: Annually [ 7. Establish written screening schedule for next 5-10 years a) USPSTF recommendations b) Immunizations and services covered by Medicare Your major risk factors: Family history of Obesity Hypertension Fall Risk Smoking Use Diabetes Other Recommendations for improvement: Diet Tobacco Cessation Weight Management Exercise Other Referrals For Staff Use: [list handouts, referrals, or other follow-up instructions here] "Men's Prevention Plan." Medicare's Annual Wellness Visit. American College of Physicians. Available at http://www.acponline.org/running_practice/payment_coding/medica re/annual_wellness_visit.htm. Accessed on Accessed on 22 Feb. 2013.

8. Furnish personalized health advice and referrals to health education or preventive counseling services or programs a) EKG b) AAA Ultrasound c) Tobacco cessation d) Fall prevention "Standard Paper HRA Profile Report." University of Michigan - Health Management Research Center. Available at http://www.hmrc.umich.edu/. Accessed 28 Feb. 2013.

CPT Code Descriptor Non-Facility Facility G0402 Welcome to Medicare $164 $123 G0403 Screening EKG $18 $18 G0438 1 St Annual Well Visit $169 $169 G0439 Subsequent Annual Well Visit $112 $112 Q2038, 90732, 90746 Influenza, Pneumonia, HBV Vaccine Admin. Cost + $25 Cost + $25 G0102 Digital Rectal Exam $20 $9 77080 DEXA Bone Density (axial) $41 $41 99407 Tobacco Cessation $27 $25 Medicare Physician Fee Schedule Search. Centers for Medicare and Medicaid Services. http://www.cms.gov/apps/physicianfee-schedule/. Accessed 25 Feb. 2013.

Assumptions 1. Multi-physician office with existing Medicare base 2. Work per Week per FTE NP and MD 32 scheduled patient care hours per week 45 weeks per year LPN and Receptionist 35 hours per week 48 weeks per year 3. Visit Workload Receptionist: 5 min LPN Visit Time: 15 min MD Visit time: 15 min NP visit time: 30 min

Assumptions continued: Salary Benefits Total Compensation Physician 1 $211,803 $63,541 $275,344 Nurse Practitioner 2 $91,700 $27,510 $119,210 LPN 2 $42,300 $12,690 $54,990 Receptionist 2 $29,900 $8,970 $38,870 Salary and benefits in New York City may be higher than the national median. 1 MGMA Physician Compensation and Production Survey: 2012 Report Based on 2011 Data, Internal Medicine, Ambulatory only. 2 CompAnalyst Market Data. Kenexa. Accessed June 21, 2011

Estimated Financial Impact NP Model MD-LPN Model Charge per visit $112 Annual Visits 2,700 Annual Revenue $302,400 Receptionist $5,206 NP $111,759 Charge per visit $112 Annual Visits 2,700 Annual Revenue $302,400 Receptionist $5,206 LPN $22,094 MD None MD $129,067 Other costs TBD* Other costs TBD* Annual Cost $116,965 Net Income $185,435 Annual Cost $156,367 Net Income $146,033 *Staff training, office overhead, IT upgrade, billing

MD-LPN Delivery Model 66 Years and Older Medicare Beneficiaries

Run Practice List of Patients 66 yrs & older Management Staff Mail Out AWV Form To Patients Front Office Staff/ Call Center Staff/ Patient Navigators Contact & Schedule Patients ASAP, Mail AWV Form Office Staff/ Med Asst/ Nurse/ LPN/ Providers/ Social Worker Telephone Encounter To Patient/ Family/ Caregiver Instruct Patients Set Appointment for AWV Complete AWV Form Over Phone Instruct Patients to Mail Back AWV Form or Bring During AWV Visit Remind Patients to Bring AWV Form Provide Appointment For Office or Home ASAP

Mrs. Test, Apple is 89 years old and has not had an AWV so our office staff reaches out to her. Hello! I work with Dr. PCP. Our practice would like you to come in for your annual wellness visit (AWV) at the soonest time. The annual wellness visit is covered by your insurance. When can you come in? If you are unable to come to the office, we can send a doctor or NP to see you at home.

In order to keep you healthy, we need you to answer several questions in preparation for the visit. Do you have time to answer them over the phone now? If not, we will mail you the form and please make sure to send it back or bring it with you during the visit. Mrs. Test requests to have the form sent and makes an appointment for AWV.

Front Office Staff LPN Primary Care Provider As patient registers, ask from patient the completed AWV form. If not done, provide patient/ caregiver the AWV form to complete while in the waiting room. Scan AWV form into EHR once reviewed by MD Do Depression Screening Reconcile medication list & click verified Ask & record Pain in vital signs Review the completed AWV form. Any answers that fall under, provide patient with additional form for further evaluation. Enter ICD9 & CPT codes for the visit. PCP to also review AWV form and ensure EHR documentation. Mandatory action plan for: Advance Care Planning Impaired ADL/ IADL Cognition Fall Risk Treatment for pain if present Consider other optional action plans if needed Verify/ add ICD9 & CPT codes for the visit.

CC: Annual Wellness Visit (AWV) HPI: Depression Screening Medication List: reconcile meds & click verified Allergies: Click verified Click verified: Medical History, Surgical History, Hospitalization, Family History, Social History Physical Examination: Vital Signs, Ht, Wt, BMI Pain Assessment

HPI: Medicare Annual Wellness Visit: please complete Care Management: Assessment: Activities of Daily Living Instrumental Activities of Daily Living Fall Cognitive Assessment Advance Directives Add note patient here for AWV; see scanned form for details ROS: NOT REQUIRED; may add note See scanned AWV form for details. Physical Examination: NOT REQUIRED except mental status & ambulation & vision

PLAN: Preventive Medicine o Counseling o Under Note Age-specific and individualized counseling done on advance care planning, healthy diet and physical activity, enhanced functional and cognitive ability, social engagement, home safety and fall risk reduction, selfmanagement goals to control or improve chronic diseases, and preventive services related to cancer screening (breast, cervical, colon), glaucoma and retinopathy screening, hearing evaluation, immunization, and blood tests appropriate for chronic disease monitoring.

Code MD ASSESSMENT V70.0 (ICD9) BILLING for VISIT G0438 OR G0439 G0402 G0405 Description Routine general medical examination Annual Wellness Visit (AWV); Patient Preventive Plan Service (PPPS) INITIAL; ONCE in a lifetime after first 12 months of Medicare Part B eligibility; can only be billed once for beneficiary by any provider AWV; PPPS Subsequent Welcome to Medicare IPPE EKG Interpretation & Report DO NOT use 99387 or 99397 not reimbursed by Medicare

Code MD Description Quality Measure Codes (CPT II/ HCSPC Codes) ADD all that apply to patient visit: 1157F OR 1158F &/ OR S0257 0521F 90862 1160F advance care planning forms on record (healthcare proxy/ living will/ MOLST) advance care planning discussion documented; actual form not on record counseling & discussion of advance care planning/ end-of-life care issues plan of care for pain documented medication management reviewed meds by pharmacist/ MD, in record

Code LPN To Enter Description Quality Measure Codes (CPT II/ HCSPC Codes) ADD all that apply to patient visit: 1170F 1125F, OR 1126F 1159F G8427 OR G8428 functional status assessment amount of pain noted; pain present amount of pain noted; no pain medication list documented, in record documented meds verified with patient or record meds documented without verification

When Annual Wellness Visit turns into something more 1. Separate and significant E/M 2. Documentation must stand alone 3. Separate ICD-9 and CPT codes a) V70.0 & G0439 b) 692.6 (poison ivy dermatitis) & 99212 or 99213 & modifier-25

AWV facilitates meeting HEDIS Quality Measures (PQRS) for Care of Older Adults Rapid implementation requires: Coordinated multi-prong approach as it impacts all elements of the patient visit Defining roles of every team member Patient, staff and provider education and training Using templates (paper/emr) as a tool