1/2011: New Medicare annual wellness visits

Effective Jan. 1, 2011, providers (physicians, physician assistants, nurse practitioners, or clinical nurse specialists or other medical professional working under the direct supervision of a physician) may report two new HCPCS G-codes for annual wellness visits (AWV) for Medicare beneficiaries. In order to report codes G0438 (annual wellness visit; includes a personalized prevention plan of service [PPPS], first visit); and G0439 (…, subsequent visit), documentation must show that the elements of the service were provided. These include:

• Establish/update individual medical and family history. At a minimum, CMS requires documentation of a patient’s “past medical and surgical history, experiences with illnesses, hospital stays, operations, allergies, injuriesand treatments, use or exposure to medications and supplements, including calcium and vitamins, and medical events experienced by the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the individual at increased risk.”

• Track care and drugs. Create/update list of patient’s regular providers and suppliers of medical care, and medications, including supplements such as vitamins.

• Physical assessment. Measure height, weight, body mass index (BMI) or waist circumference, blood pressure and other routine measurements as appropriate, based on the patient’s medical and family history.

• Check for signs of cognitive impairment. CMS defines this as “assessment of an individual’s cognitive function by direct observation, with due consideration of information obtained by way of patient report, concernsraised by family members, friends, caretakers or others.”

• Establish/update a schedule of screening services. This should be a written schedule, such as a checklist, that sets patient-appropriate tests for the next 5-10 years, based on government recommendations and the patient’s own health status, screening history and age-appropriate preventive services that Medicare covers.

• Establish a list of risk factors and conditions for which interventions are recommended or already underway. These include any mental health conditions or risk factors/conditions identified through an initial preventive physical exam, along with a list of treatment options and associated risks and benefits.

• Furnish personalized health advice and referral where needed to health education or prevention counseling services or programs. CMS clarifies that physicians may separately bill for all preventive services (those covered without requiring a copay in the final rule) in the same encounter or day as the AWV.

• Screen for depression. This should include a review of the patient’s current or past experiences with depression or other mood disorders, based on use of an appropriate screening instrument. Depression screening is only required during the initial AWV (G0438).

• Screen for functional status . The clinician may use direct observation or tests to check for (at a minimum) hearing impairment, fall risk, home safety and the ability to successfully perform the activities of daily living. Functional status screening is only required during the initial wellness visit.

UPDATE ON RED FLAGS RULE: IT DOES NOT APPLY TO PHYSICIANS

In September of 2008, I first posted information on the Red Flags Rule, which requires lenders to develop plans to ensure that consumers’ financial information is kept secure. Its implementation, however, has been much debated by the health care industry, particularly the AMericna Medical Association (AMA), which declared that the rule was not appropriate for physicians. Now, due to an end-of-year action by Congress soon to be signed into law by the President, it is clear that this rule will not apply to physicians.

The rule, separate from HIPAA patient-privacy rules, required creditors to demonstrate a protocol “for detecting identify theft red flags, preventing and responding to identity theft, and for keeping their programs up to date.” Under the Federal Trade Commission’s interpretation, physicians had been considered creditors if they bill patients for fees not collected at the time of service—which applied to almost all practices. The new interpretation exempts physicians from the category of “creditors.”

Physicians, of course, are given credit/debit card and banking information by patients and must still be careful to secure this financial data. However, formal steps outlined in the Red Flags Rule are now not required.

Cynthia Newby, CPC, CPC-P

December 14, 2010