Annual wellness visit assists value-based payment goals

The term "an ounce of prevention" takes on new meaning in the era of value-based reimbursement and the Medicare Access and CHIP Authorization Act (MACRA), with their focus on wellness and preventive care.

In this new environment, providers and clinicians are charged with improving quality and reducing costs, says Daniel Bluestein, MD, CMD, a family medicine and geriatric physician.

He's also professor and director of the geriatrics division in the Department of Family & Community Medicine, Eastern Virginia Medical School, and practices independently in both Norfolk and Portsmouth, Virginia.

Bluestein is an expert on the revenue potential from the Medicare Annual Wellness Visit (AWV), added as a benefit of the Affordable Care Act in 2011. Here's what he says you should know to maximize this specific visit for your patient and for your practice.

1. It's different from and better than a 'regular' physical.

This is an opportunity to really coordinate care, he says. It's a time to talk proactively about the "whole" patient, especially their medical and family history and current health conditions, along with medications and supplements. The provider can also obtain specific vitals, such as height, weight, body mass index, blood pressure and vision, and discuss recommended screenings and vaccinations.

"If necessary, providers can still add a significant, separately identifiable evaluation and management (E/M) service code from the same physician on the same day of the procedure or other service if applicable," Bluestein says. "For example, if the patient brings up an ‘Oh, by the way, doctor’ topic that's then discussed during the AWV, use the 25-modifier."

The wellness visit is also a golden opportunity to discuss the extremely important topic of advanced care planning and for referrals to community-based health resources if applicable.

Next: Paying the practice back

2. It pays the practice back.

"You do get reimbursed over and above standard office visit Current Procedural Terminology (CPT) codes," Bluestein says. Understand that for this year, Medicare allowances for HCPCS codes G0438 (initial AWV) and G0439 (subsequent AWV) are $173.70 and $117.71, respectively. Note that the charge for CPT code 99214 (level 4, established-patient office visit) amounts to $108.74.

In addition, the CPT code 99497 for the first 30 minutes of advanced care planning is $86 and for each additional half-hour, $75. "There is no copay if these codes are used in the context of the AWV," he says. "CMS (the Centers for Medicare & Medicaid Services) makes it possible for you to get more meaningful reimbursement for services not so well covered in the past."

He reminds clinicians that value-based reimbursement calls for documenting quality improvement and the conduct of practice improvement projects, and that the wellness visit is a vehicle for meeting those stipulations for MACRA and MIPS (the Merit-based Incentive Payment System). 

"Whether completing wellness visits can reduce hospitalizations and attendant costs remains to be seen, but the potential is clearly there," he says.

3. Invest to support success.

In the office: "One drawback is that these codes have specific requirements, and to learn how to meet them, you've got to work at it and this takes time," Bluestein says. "You need proper documents in place and correctly filled out that support the visit, and a staff that understands them. Make sure you ask for input and that everyone's on the same page."

With patients: At his institution, a 2016 internal survey revealed patients had few attitudinal barriers, that physician advocacy was important and that most patients had never heard of a AWV, but wanted one when they did. "Additional encouragement from 'staff champions' to further explain physician recommendations is also key," he says.

Historically, the uptake on patients taking advantage of AWVs is quite low. A 2014 CMS report shows that a mere 14.5% of eligible Part B fee-for-service beneficiaries took advantage of the service.

"Patients have to have buy-in," says Bluestein, "and they need to understand this visit isn't a physical and this isn't the time to come in about a sore knee."

Remind patients they can have an initial AWV in their first year of Part B eligibility, and then an ongoing, subsequent AWV starting in their second year of eligibility, Bluestein suggests. The visit itself is 100% covered by Medicare, though there may be other charges for immunizations, lab draws, etc.

"It's also a way to further engage patients and encourage their loyalty," he says. "Patients generally like these visits. The strongest predictor of getting further wellness visits was having an initial one in the first place."

Next: The AWV as a means

4. The AWV is a means and not an end.

This is the clinician's chance to spend quality time, usually 40 minutes to 60 minutes with a patient.

The conversation may yield an open exchange of information, and the patient may disclose other problems that require follow-up care-for which the practice really can bill. Remember, too, that the initial visit and follow-ups can be accomplished by the physician, or by a physician assistant, nurse practitioner or other medical professional or team directly supervised by the physician.

5. It's for the greater good.

"Remember that your interventions with the annual wellness visit may reduce the likelihood or reduce the duration of more serious problems later for a patient," says Bluestein. "With value-based reimbursement, if you hit your quality metrics while encouraging wellness, you also have the potential to reduce costs and even do well on the CAHPS (Consumer Assessment of Healthcare Providers and Systems) Survey. The wellness visit encourages and supports practices in efforts to achieve and demonstrate better patient-centered outcomes.”