The Center for Medicare and Medicaid Services (CMS) has pushed for a multi-pronged strategy to increase investments in primary care to ensure not only their clinical but also their financial growth. CMS understands and acknowledges the value of primary care particularly in transitional and care coordination services by creating additional codes so Primary Care Physicians can get paid for the services they provide.
Annals of Internal Medicine
However, a recent study in the Annals of Internal Medicine has shown that Primary Care Physicians are missing out on as much as $200,000 a year by not utilizing Medicare’s prevention and care coordination billing codes as frequently as they should.
The study looked into the potential and actual billing for 19 prevention and 15 care coordination codes, which represented 13 categories of service stipulated in the Medicare Physician Fee Schedule (MPFS) from the years 2005 to 2020. These codes are designed to cover the different services that Primary Care Physicians often provide without being paid for them. In the same manner, the codes are supposed to entice Primary Care Physicians to offer services that highly benefit patients.
Primary Care Physicians are billing for only a small fraction of patients they treat.
The study used two kinds of estimates to compute the range of annual revenue that a full-time physician could potentially earn using the codes for every service category, depending on the specific type of practice and their patient population mix. The first one is for services already provided by the PCP but not being billed and the other calculates how much they could earn for the services if they billed only for half of their eligible patients.,
Primary Care Physicians and Medicare’s incentives
The study shows that Primary Care Physicians are not fully capitalizing on Medicare’s incentives despite having sufficient eligible patients. Here are some of the important findings:
- Medicare eligibility for each service ranged from 8% to 100%.
- The billing code median use was only 2.3% even if PCP use the appropriate prevention codes for 5% to 60.6% of their eligible patients.
- Around 22.5% of Medicare patients were recently hospitalized and qualify for Transitional Care Management (TCM). Out of these qualified patients, 43% sought primary care after they were discharged.
- For Chronic Care Management (CCM), 66% of patients were eligible, 33% for Behavioral Health Integration (BHI), and 10.5% qualified for cognitive assessment with care planning services. However, less than 3% of eligible patients participated in the said services.
If Primary Care Physicians have billed for all their preventive and care coordination services to just half of their eligible patients, they could earn annually as much as $124,435 for prevention and over $86,000 for coordination services.
Documentation Requirements for the Medicare Annual Wellness Visit
Documentation requirements for the initial Medicare annual wellness visit are as follows:
Assessment of health risks.
The Medicare annual wellness visit must include a health risk assessment (HRA) to be completed by the beneficiary or healthcare provider. The HRA should not be overlooked but, at minimum, should consist of demographic data; self-assessment of the individual’s health status; psychosocial and behavioral risks; activities of daily living (ADLs), such as dressing, bathing, and walking; and other instrumental ADLs (IADLs) including shopping, housekeeping, medication management, and finances.
A medical history and a family history.
A beneficiary’s medical and family history should include as much detail as possible, including hereditary and high-risk conditions, past medical and surgical history, and medication use, including prescriptions, over-the-counter medicines, vitamins, and supplements. Healthcare providers should discuss, assess, and document opioid use in light of the current opioid crisis.
Providers and suppliers currently in operation.
It should include all current healthcare providers and suppliers that regularly provide care and services to the beneficiary, such as primary care physicians, specialty physicians, chiropractors, acupuncturists, pharmacies, herbalists, and therapists.
Measuring routinely.
It is important to take important, routine measurements. These include height, weight, body mass index/waist circumference, blood pressure, and any other measurements that are appropriate based on your medical and family history.
Cognitive function.
Through direct observation, assess cognitive function (including Alzheimer’s disease and other forms of dementia) and document the results. Take into account information from beneficiary reports and any concerns raised by family, friends, caregivers, or other individuals who regularly interact with the patient when making this decision.
Depression risk factors.
Review a beneficiary’s potential risk factors for depression using a depression screening test (such as those developed by the American Psychological Association).
Safety and functional ability.
Analyze a beneficiary’s functional ability and safety, including their ability to perform ADLs, fall risks, hearing impairments, and home safety, through direct observation and/or through screening questionnaires.
Schedule for screening in writing.
If healthcare providers fail to abide by documentation standards, they are likely facing the issue here. They need to craft a written preventive screening and services plan for the next 5-10 years of the beneficiary’s needs. This part of the personalized prevention plan of service (PPPS) is essential, so in this blog we examine how it works and expand on several suggestions on how to make it better. Especially important is our point about…
A personalized prevention plan and advice are expected to be provided to patients as part of the regulations. In spite of the fact that furnished is not defined specifically, it has been interpreted to mean either a physical copy of the PPPS given to the patient upon completion of the AWV or a copy placed in the patient’s active health portal.”
Factors and conditions that increase risk.
Create a list of risk factors and conditions that need to be addressed – either primary, secondary, or tertiary. Mental health conditions, such as depression, substance abuse, and cognitive impairment, as well as any risk factors or conditions uncovered during the initial preventive physical examination (also called IPPE or “Welcome to Medicare” preventive visit); and treatment options and their risks and benefits.
Referrals and advice on health issues.
Health care providers should provide beneficiaries with personalized health advice and document it. This would include referrals to health education and/or preventive counseling services and programs aimed at lifestyle interventions to promote wellness in areas such as weight loss, increased physical activity, smoking cessation, fall prevention, and improved nutrition.
ACP services are available upon request
Health care providers should discuss advance care planning (ACP) services with beneficiaries who are comfortable with it and document the discussion. ACP discussions should cover topics such as how patients can inform others about their care preferences, identifying caregivers, and explaining advance directives (which may require the completion of forms).
Annual Wellness Visit (AWV) Practice Checklist
The 12 items needed for a Medicare-compliant wellness visit
Follow this Medicare annual wellness exam checklist to ensure every AWV is documented and completed properly.
1. The first step is to verify eligibility
Medicare, along with all types of insurance providers, has rules for what services patients are eligible for and when. In the case of annual wellness visits, the timing of the appointment is particularly important. A patient may be eligible for an AWV appointment if they have been enrolled in Medicare for more than twelve months and have not been for a wellness visit or a “Welcome to Medicare” preventive visit in the prior twelve months. Determining eligibility can be a challenge.
Since it’s usually completed over the phone, through the MAC portal, or through a clearinghouse, it’s a time-consuming process if not automated. By verifying eligibility before any services are provided, both the provider organization and the patient can avoid the financial burdens that can result from rejected claims.
2. Communicate expectations and requirements
Providers and patients work together to maintain preventive health. Organizations need to proactively communicate with patients about what they need to do to prepare for their annual wellness visit, including what information they should bring to the appointment, so patients are fully prepared. Patients should also be made aware of what to expect from their visits.
Some people believe Medicare annual wellness visits will include a physical exam or other diagnostic procedures. If you are wondering why Medicare doesn’t cover annual physical exams, read this blog post. It will help patients avoid confusion and frustration if they understand in advance what an AWV entails.
3. The patient is responsible for completing a health risk assessment.
This Medicare annual wellness exam checklist includes a critical step: asking patients to complete a health risk assessment (HRA) because HRAs help providers identify factors that could adversely affect patients’ health. Additionally, they provide clinicians with the information needed to reconcile patient responses with existing medication and health records, as part of Medicare’s AWV.
Digital assessments should be completed before the patient attends their appointment. Patients can allocate time to gather the necessary information by completing them in advance, such as their family medical history or medication names and dosages. Even if someone completes a health risk assessment in their office, Ascent care partners can simplify the process for them and their providers.
4. Find out who your current medical providers are
The creation of a record of each patient’s providers, including pharmacies and medical equipment suppliers, is essential to understanding current and future medical needs.
5. Measuring routines
In addition to collecting vitals and other measurements at the Medicare annual wellness visit, other vitals are also important. It is possible to identify concerning trends in a patient’s health by tracking information such as weight, blood pressure, and body mass index over time.
6. Assessment of cognitive abilities
As a result of diminished cognitive abilities, some Medicare patients may have difficulties caring for themselves and negatively impact their quality of life. By identifying cognitive decline earlier, it is possible to keep patients healthy and safe by assessing their cognitive awareness.
A cognitive assessment may be conducted using formal tools, such as those provided by the National Institute of Aging, or it may be completed using direct observation and input from family members, friends, and caregivers.
7. Assessment of mental health
More and more patients are suffering from mental health conditions, including depression. As providers work to identify and address these conditions, they can use many screening tools, such as those provided by the American Mental Wellness Association.
8. Assessment of everyday living and safety
As patients age, they may lose the ability to complete activities necessary for everyday living. Therefore, screening for concerns such as a patient’s inability to fulfill their nutrition or hygiene needs is essential. To assist in keeping patients safe, it is also vital to determine if their environment does not put them at undue risk of falls or other accidents.
9. Document the risk factors
Using the information gathered from all of the recommended assessments, it is important to compile and document a list of possible risks that may negatively impact a patient now or in the future. The risks themselves and the advantages and disadvantages of any treatment options should be included in this list.
10. Plan for the future
After gathering information from the AWV, the final step of the in-office Medicare wellness visit process is to provide the patient with guidance on how to maintain or improve their health. This step includes three steps:
- Identify specific medical advice and strategies for addressing identified risks and provide a personalized plan to the patient.
- Together with the patient, develop a screening schedule that provides a checklist for all recommended preventive medicine screenings over a five-to-ten-year period.
- A third step is to provide a physical copy of both the personalized patient plan and preventive screening schedule to the patient.
Automating these steps by using technology can significantly reduce the time and risk of errors associated with creating the screening schedule and personalized plan.
U.S. Preventive Services Task Force (USPSTF) recommendations should be incorporated into this checklist.
11. Coding and billing correctly
After a patient’s appointment is finished, it’s time to ensure the proper coding and billing of services is done. Getting this step wrong can have costly consequences: rejected claims or penalties resulting from a compliance audit. Both mean potential lost income for the provider. For help with the rules associated with Medicare AWV coding and billing, read this post.
12. Advanced care planning (ACP) is optional
We included an asterisk with item 10 of the checklist for the Medicare annual wellness visit, as there may be an extra step: advanced care planning (ACP). This is optional but covered by Medicare. These discussions and documentation could involve finding out who a patient trusts to make medical decisions if they can’t communicate, or which interventions they are comfortable with. However, some patients may not feel comfortable discussing these topics and this should therefore be left to their discretion.
Subsequent Medicare Annual Wellness Visit Documentation Requirements
After a beneficiary’s first annual wellness visit, the following documentation requirements must be met:
HRA should be updated
The beneficiary’s medical and family history should be updated
Providers and suppliers of healthcare should be updated
Measurements that are routine and essential should be documented
Analyze cognitive function
Identify and discuss the risk factors for depression
Schedule the written screenings
Update risk factors and conditions for which interventions are recommended or underway
As needed, update the prevention plan of services, including personalized health advice and referrals to health education and/or prevention counseling programs.
Review/discuss advance care planning services at the patient’s request
Why are Primary Care Physicians not billing for their services?
Even with code-appropriate services, Primary Care Physicians are missing out on Medicare revenue simply because they are not billing for them as they should.
Here’s why Primary Care Physicians are not fully using Medicare’s prevention and care coordination codes:
1. Complex requirements to get paid
It takes too much time and requires a lot of effort to meet the requirements on eligibility, documentation, and the time and component of care for providers to bill for the codes and get reimbursed. Providers even believe that some requirements can be too prescriptive or even inappropriate.
2. Upfront investment needed
Even if doctors are well aware of the codes and the documentation requirements, they are hindered by the huge capital investment they need to set up the program including the personnel, technology, and infrastructure.
3. Too time-consuming
Others think that the time requirements may cause disruptions to their workflows and even hinder them from providing other essential services. To illustrate, in meeting the recommendations of the U.S. Preventive Services Task Force, providers may need more than eight hours a day.
Furthermore, the authors of the said study reiterated that the additional codes for TCM, CCM, and PCM in the MPFS are designed to strengthen primary care in the country. However, the study has shown that this part is not yet fully realized. It might be better to utilize time-based billing as a payment method or global capitation which is more suited to the various activities provided by primary care.
How can Primary Care Physicians maximize revenues?
Even before the 2022 MPFS was fully implemented, primary care in 2021 posed a significant increase in net patient revenue per physician at full-time equivalent with 12.9% growth from the third to the fourth quarter according to Kaufman Hall’s physician flash report. Patient volume increased as many care services were deferred during the pandemic. However, this gain is countered by labor shortages and high cost of operational expenses due to inflation.
Primary Care Physicians Medicare’s Incentives
Hence, Primary Care Physicians have all the more reason to capitalize on Medicare’s incentives to ensure their practice’s financial status, which could significantly impact the quality of care they provide.
To fully utilize Medicare’s prevention and care coordination codes, Primary Care Physicians need to think of a solution that enables them to navigate the complex requirements, avoid increased overhead, and improve their quality of care, particularly for their high-risk and high-cost patient population.
The most practical and profitable solution is to outsource essential services to a third-party vendor who has the technology, devices, personnel, and capabilities to fully implement these preventive and care coordinated services, namely, CCM, PCM, TCM, BHI, Annual Wellness Visits (AWV), and Remote Patient Monitoring (RPM).
Ascent Care Partners (ACP) offers virtual healthcare services as full services to help primary care practices realize much-deserved revenue and avoid the pitfalls of starting their own programs. We assist practices from patient enrollment to the preparation of billing charges and even as they scale up to fully maximize Medicare codes. With ACP, Primary Care Physicians will no longer miss out on Medicare revenue that helps them optimize their patient care while they see their practice grow financially.
We partner with the following providers:
- Primary Care Physicians
- Family Practice Physicians
- Internists
- Gerontologists
- Non-Interventional Cardiologists
- Endocrinologists
- Wound Care Doctors
- and other doctors
