Episode 122: Understanding Annual Wellness Visits for Healthcare Organizations

Coffee with Coker is a healthcare business podcast from the Coker Group that focuses on solutions to help healthcare organizations effectively navigate the changing healthcare industry landscape. Hi everybody. Welcome to our Cast today. My name's Jaci Kipreos, and I am the director of provider audit services here at Coker.

And I am fortunate to have as my sidekick today, Erika Fisch, who's also at Coker. I'm going to let her introduce herself, and then we're going to tell you what we're talking about today. Hi there, as Jaci said, I am a member of the Coker team and I am an auditor and educator who works with physicians on their documentation and their coding. Great.

And as the director of provider audit services, I get to oversee the audit. So Erika and I work very closely together. We learn from each other, which is a fabulous experience. I know for a lot of folks who joined the Coker podcast, a lot of times.

What you hear about is revenue cycle, physician compensation, a lot of information about financial aspects. Because of what we do, we're in the coding and compliance department. We, as Erika said, we work with provider. audits.

So we see a lot of different challenges that provider offices are dealing with. There's a lot of billing issues, documentation issues, policy issues, new codes every year. We thought it'd be really nice to start a podcast series for practice managers. Auditors, billers, coders, people who need to know more about those day to day operations and the challenges that you have.

Erika and I came up with the idea. Everybody's behind us. And of course, because it was Erika's great idea, I said, so Erika, what do you want to talk about first? And what was your answer?

What's our topic today? We are going to talk about annual wellness visits. Annual wellness visits, so what do you mean? What's an annual wellness visit?

So, Medicare has a yearly benefit for their beneficiaries called an annual wellness visit. And the reason I chose this topic is because no matter the type of client I look at or the type of documentation that I look at across all EMRs, I find that there is usually something that can be improved based on the review that I do for these annual wellness visits. So I thought it would be a good topic to start with because there's a lot of nuances. with annual wellness visits.

That makes sense to me. Now, I may be aging myself, but I've been in the business of healthcare for over 30 years. And I remember when annual wellness visits and IPPEs were first created by Medicare. Um, and I remember it was a great idea.

Do you remember when they were created, Erika? I sure do. And I actually helped with the implementation where Where I worked, so that's fantastic. And it was it's a great benefit for Medicare beneficiaries.

So does that mean, and I think this is one of the confusion some people have when we say Medicare beneficiary. Does this mean you have to be 65 to take advantage of this benefit. No, that is one of the confusing factors about this benefit. So for a annual wellness visit, the first one is the IPPE or that Welcome to Medicare.

The IPPE stands for Initial Preventative Physical Exam. That benefit is for the first 12 months of your Part B Medicare coverage. That means you could be 24 and have an IPPE or you could be 67 if that's when you start your Part B coverage. So it's really important to include that front desk staff or the registration staff in the process to ensure that we can capture these.

initial visits. And when you say Medicare, are we talking straight Medicare or would this be an HMO policy as well? Both. It includes both straight Medicare and those HMO replacements.

Yeah. Absolutely. So we're talking IPPE, which is that G0402. And then with the annual wellness visits, there's actually two codes that we use a G0438 and a G0439.

What's the difference there? Yes. So we have the initial annual wellness visit, which is the G0438. Now that is when you are past that first 12 months, you then get to have your initial annual wellness visit.

Once that benefit is reached, you get to have a subsequent annual wellness visit. So beyond that, beyond having that initial. Annual wellness visit every year after that would be a subsequent annual wellness visit. Right.

So, your 1st, 12 months, you have an, the year following if that patient chooses to do so, they can have their initial, which is a, then every year after that, if they continue to want that benefit, they can go with a G0439, sounds easy to me. I can't understand why there would ever be a problem with any of that. So. I understand that Medicare.

created these as a benefit for patients to make sure that they are getting their follow up care and kind of have a gatekeeper. I know that goes with HMO language, but someone that's kind of overseeing everything that they're doing. Am I kind of in the right place there? Absolutely.

So, another thing to kind of help understand the concept of the annual wellness visit is that we have to define the difference between an annual wellness visit and a Preventative physical exam. A preventative physical exam is something that commercial payers or what you consider like your routine physical. And that is a visit where the doctor looks at you head to toe, gives you an exam. determines if you have any specific conditions that might warrant further follow up.

That's not what an annual wellness visit is. The annual wellness visit is intended to be a, like a gatekeeper to your preventative care. They want to make sure that you are utilizing the preventative benefits that Medicare provides by having this as their yearly checklist to ensure that you are utilizing the benefits to ensure your health for the future. So my understanding is there is a lot of information here.

There are a lot of guidelines that have to be followed. What are your best resources for making sure when you're performing an audit that the documentation is supporting everything that has to be included in these different types of, uh, codes or services? Absolutely. So, Medicare has some excellent resources on their websites for the understanding of not only the difference between the Welcome to Medicare and the annual wellness visits, but they also talk about why it's different from that.

Uh, preventative physical that I just talked about. So it outlines the difference between the three. There is a interactive tool to help explain what needs to be in each of the different templates for each of the services to have it be a supported service. And then for the billers and the coders, there's also the claims processing manual, which will help include the information that you need to file the claim appropriately.

And I will have the links for both of these resources in the podcast notes that you can easily reference. Fantastic. So getting back to just what we're I know there are differences between that IPPE and the annual wellness. So I'm gonna, when I say annual wellness, I'm talking about initial and subsequent.

So we're gonna use I-P-P-E-A-W-V. I know that when. I look at these. It's really a list of questions.

It's not an exam. It's a list of questions that are posed to the patient and they have responses and that allows whoever's obtaining that information to get kind of a baseline on how the patient is. So who can perform these? Is it the same?

Anybody can perform them because it's just a bunch of questions. So for the first visit that IPPE, that needs to be done face to face. And it needs to be done by a billable clinician. So an MD, DO, NP, PA, someone in that capacity, someone who's able to put their name on a claim form.

Correct. And not someone who is working under the supervision of them. It needs to be someone themselves billing for that service. Now when we move to the annual wellness visit, those ones can be done by ancillary staff, a nurse, a care coordinator.

Where someone else is able to perform that service. Based on the direction or under the direction and supervision of. 1 of those billable providers, so 1 of those billable providers would then. Sign off on that.

Yes, so we would see their name and a true, correct signature. Someone else. Could obtain the information and we, I would think from an audit perspective, we'd want to know that person's name as well. Absolutely.

It would be important for us to know who performed the service as always. We want to know who performed the service and then who is directing and supervising the service at the same time. So, we've talked about CPT codes. We've talked about what goes into this.

We're going to start drilling down into some more details. What I find interesting, and I know you and I have talked about this before, what does Medicare say about diagnosis codes that are attached to these codes? That's a very interesting question because they don't give us any direction on diagnosis coding for this specific code. They oftentimes give us something specific to use on each code, but this one says use any appropriate code.

Generally, we would like to see a wellness visit code, those Z0000 or Z0001 if an abnormality is found during the visit, but that is not spelled out by Medicare. No, it's interesting and they take a lot of detail on that CPT front end and it's really not clear. So, when you go and hopefully you will take an opportunity to reference the resources that Erika is going to provide for you, you'll see consistently there's no exact, um, Reference to a diagnosis code now along these lines, you know, every practice is going to have their own policy.

So a lot of things you might want to create your own policy. We want to do it this way. And then it makes it very clear for new providers, everyone in the group to understand what your policy may be for that. Excellent.

So. When you're reviewing either the IPPE or the AWV , and what are some of the main, most common, I would say, most common audit findings when you're reviewing these? What are the things you see rather consistently, and it doesn't matter where the practice is, we're not talking about any particular geography, any particular type, it's just consistently any practice across the country, what are some of the most frequently seen variances? What's getting missed?

One of the biggest things I see is that the patient isn't identified as needing the initial IPPE visit. And so one element of the IPPE is the visual acuity exam. And without that visual acuity exam, the visit is not a billable service. So you need to have somewhere along in the process, have it be indicated that that initial IPPE is needed, not just an annual wellness visit.

There needs to be buy in from the front end, the schedulers, and the rooming people as well, the person who is going to perform that visual acuity exam, to be able to properly perform that visit. Another thing that I see is. There were relatively newer add ons to the annual wellness visit requirements, and that was the psychosocial risk factors, and the opioid screening, or the substance abuse screening, and the opioid prescription review. Those are the ones that I see missed most often.

And. I highly suggest utilizing your EMR to update your templates to ensure that those are in there and consistently using your appropriate templates. So that's psychosocial and the substance abuse and the opioid. Those are relatively new and they relate to the AWV.

Are they right? Correct. And if you use your. Cheat sheet or references that Medicare spells out for us, you'll know exactly the requirements for that PPE.

You know exactly the requirements for the AWV. And I think Erika's point is an important one. As we know, with Medicare, all you, if one thing is missing, just one, you've lost it all. And it seems silly.

It's just, that's the way it is. It's a complete service in that one code. Now, there's, you know, certainly we can't change the rules. That's the way it is.

So, this is a great time to maybe start looking behind yourself. Start thinking about, you know, is our template updated? Do we have all our so called ducks in a row to make sure and do a little self audit. And see where you stand with all of that, because I think those three things I know in reviewing some of the audits, that's what keeps coming up over and over and over.

So let's branch out from that and kind of think out of the box a little bit. I personally have never seen this, but I've heard of this. So what happens if a patient just refuses? I don't want to answer that question.

It's none of your business, whatever it may be. How do you handle that? If you document that you have. attempted to obtain a piece of information, but the patient does not want to answer, you know, for like the cognitive or the opioid prescription review or the substance abuse screen, they say, I would prefer not to answer.

If you document that you obtain or attempted to obtain that information and document that, that satisfies that requirement as being met. So I know That part of like review of systems, family history, social history, a lot of that gets pulled into these notes and sometimes in the social history, it'll say patient does not drink alcohol, none, never have, doesn't do it. Does that, do they still have to go through the alcohol screening, those types of questions? Absolutely.

There are specific questions that need to be answered within the health risk assessment for each time the patient presents for their annual wellness visit. And then for the subsequent visits, it needs to be updated each time. Interesting, isn't it? So as long as we're documenting that the patient didn't want to answer a particular question and it is documented as to why, then we're okay.

We're in the good, so to speak, for that. One thing I do want to mention about that is that I have seen inconsistencies with people trying to document that patients didn't want to answer something, but then they left the other templated statements within their documentation. So, if you are going to indicate that a patient didn't want to answer a question, don't leave the question. Pre populated with an answer in there.

Make sure that you're not providing conflicting information within your documentation because that would be a flag. Yeah, that kind of starts to lose the integrity of the whole note when that happens. Absolutely. Um, what about because I know I get a lot of questions about this.

So from an audit perspective. Patient shows up for their either one, IPPE, AWV, but based on their age or timing, they also need, it's time to update your cholesterol or draw some labs, PSA, whatever it may be. How do you code for those? Is that a part of those or can they be coded separately and what are you looking for in the documentation?

So those are not included in the annual wellness visits and they are a completely separate portion of The visit, so if you were going to address those. topics at that visit, you would be able to potentially bill an additional E& M on that visit if documentation supports it. It's important to know that that annual wellness visit is a administrative type visit. It is just questions, answers, filling stuff out within the EMR.

And making sure that the patient has the resources available to get any preventative services moving forward. If they have high cholesterol, high blood pressure, and they need to have their labs updated, their prescriptions renewed, anything along those lines. that is outside of that annual wellness visit and would be captured with an additional code. But that is a whole nother topic that we will discuss at a future podcast date.

Right. So, I know that a lot, there is a code for a screening EKG. Now, how does that work? So, one of the benefits That comes along with the IPPE is a one time screening EKG, but it has to be done at the time of the IPPE.

So say the patient misses their, their IPPE because they didn't be, they weren't seen within the first 12 months. They no longer get that free EKG. Then how, so let's say they're just coming. And it's AWV.

They missed their IPPE. They're in for an AWV and now they'd like an EKG. Is that just billed as a regular EKG at that point or is there, it's now they've lost their free one with the G code. It's an EKG.

Correct. There would need to be some sort of medical necessity for it to be billed appropriately. Potential AWV or potential, um, ABN scenario in that. So if something's missed on that IPPE, such as it's a missed opportunity for the patient.

Yeah. Missed opportunity for that provider to have information. I think when. We're I think it's hard.

I do understand that within the practice. There's so much to keep up with it's difficult to remind patients. Hey, don't forget by your age group. You're going to be, you know, you're going to be up for an I.

P. P. E. It's hard to remember all these things.

It's hard to remind our patients and we want our patients to have information. So it's difficult to Pull the team together to make sure that everything that should be done for patients are getting done. But these are easily missed opportunities because Medicare is going to pay for them if they're documented correctly. I think it's a really important topic and it's something that I'm not going to say it's easy to do.

It is time consuming. They create a lot of time. And I think this is something we've talked about as well. I think the biggest confusion for patients is they believe they're going to get a physical that day.

They believe it's going to be hands on physical. And when all it is, is a series of questions, they get very upset and they want their physical. So when they want their Physical, we know that Medicare isn't going to reimburse for that, um, CPT code for that annual physical, you know, that CPE complete physical exam and some patients of some patients that present for this truly have chronic conditions. That should be addressed.

And as Erika was saying, that is a whole different topic. It's one of the, no one likes to talk about it, but our next podcast, we are going to jump in and tackle that conversation of the 25 modifier. So stay tuned for that one. And we'll talk about what to do with those chronic conditions and wellness on the same day.

Well, we've covered a lot of different things and one thing that I've worked in practices before you've worked in practices before, and I think we both agree one way to get through this is that big team approach. And you've kind of alluded to that. Some of your answers so far, I think this is a topic that requires the whole group to get together and talk about it. I mean, if your front office doesn't really, if they have not been educated, no one's born with this knowledge, if they have not been educated to understand what these things are, they may not be aware of the proper questions to ask if they're scheduling, if they answer the phone and they don't know the difference between what a, uh, complete physical exam is and what an annual wellness visit or an IPPE is.

They may not be giving the correct information to the patient on the phone or if they don't know that they need to look at Part B Medicare coverage versus Medicare Part A coverage for that when they become eligible for that. visit. It's really important that everybody has the same definitions for the topic and everybody understands the importance of how we move the process from patient initial interaction with the phone or the scheduling throughout the process because it everybody.

is part of the process to get this claim paid. Takes a village. It sure takes a village. And I think that one thing that you said that's really key is the scheduling because that IPP has to be performed by a so called, you know, provider, but the AWV can be performed by ancillary staff.

Yes. And that's key to scheduling. And I think we touched on this, but just to be sure, let me go back. Telehealth.

Yes, so the annual wellness visits, both the initial and the subsequent annual wellness visits, are able to be done via telehealth. The IPPE cannot. It needs to be done in person. with that billable provider.

Got it. Wow. You are a wealth of knowledge. Well, thank you.

I do hope, well you are, and a pleasure to work with. I do hope that anyone listening, um, will take the time to check those resources and Part of me hopes that you're listening and we're just singing to the choir and you get confirmation that yeah, we're doing it. Right. That would be fantastic as well.

Our goal here is to provide topics that just kind of open your eyes to things that are going on to remind you that even if this isn't the main part of your practice, there's something you still should be looking at. If you have topics you'd like for us to. Talk about let us have some feedback. Um, we would love to get your feedback.

We've got some topics of our own that we think would be great. We want to bring everyone's attention to our coding and compliance part of Coker along with our finance and other divisions as well. But, um, we want to do this and we'll be bringing some guest speakers along the way. We have a lot of people who want to join us to bring in a lot of different topics, but I think we've covered it all.

Any last words there, Erika. One of the last things to remember is that you should be checking with your MAC because there may be some additional requirements or recommendations that they have on their website. So be sure to check out. what your MAC has to say about annual wellness visit documentation.

And it's just important that you take a look at what you have right now. And if you aren't utilizing your EMR to the, uh, best ability that it can to reach out to those people to see if there's something they can do to make this an easier process for you. Because Let's work smarter, not harder on these because it's a lot of work to get all of those requirements met. So agreed.

Well, thanks for joining us. Hope to have you join us again at our next podcast, where again, we will talk 25 modifier. We're scared, but we'll do it. We can do it for everybody.

Yes. All right. Have a great rest of your day. Everybody.

Thanks for joining. We hope you enjoyed that episode of Coffee with Coker, and we thank you for listening. We want to encourage all of our listeners to participate and contribute in the podcast. Uh, so if you have any questions, uh, on any of the things we discussed in this episode, any of the topics that were presented, please feel free to ask us.

Also, we welcome your feedback and suggestions. If you have any ideas Uh, related to the, the material we discussed in this episode, or again, or in any episode, please let us know and we'll make sure to incorporate it. And if you have ideas for topics you'd like to hear more information about in future episodes, please send those suggestions to us. We'd love to hear them and we'd love to incorporate them into our future episodes.

Uh, you can find us online and on social media. Start with our website and specifically the podcast is copywithcoker. com. You can also find that through the main Coker website at cokergroup.

com. You can also find us on social media, Twitter at Coker group. And then on LinkedIn, you can search for Coker group and find our page and the page for some of our team members as well there. So you can find us and reach out to us a number of places.

And then if you want to contact us directly, one of the best ways to do that. Email feedback at coca group. com that's feedback at coca group. com.

And again, we'd love to get your feedback and we'd love to encourage everyone to subscribe to the podcast so that you can be notified when future episodes are released. We look forward to. Uh, the next episode, and we look forward to getting your suggestions and feedback on this episode. Thanks for listening, and we look forward to speaking with you again on future episodes.

The information presented and discussed in the Coffee with Coker podcast is intended strictly for informational purposes only. Listeners are solely responsible for employing their own research methods when weighing, valuing, and considering the information and recommendations provided by Coker. The content included And the Coffee with Coker podcast should not be treated as financial or investment advice. The information presented in this podcast is not legal advice, nor should you rely on the recommendations contained herein as a legal opinion.

All information contained in this podcast is considered current as of the date of the recording of this material, but laws, regulations, and payer requirements are subject to change. And Coker has no responsibility to update this podcast to reflect any such changes after the date this podcast was recorded.