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Understanding the Medicare Wellness Visit Guidelines

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Understanding the Medicare Wellness Visit Guidelines

by Lucy Lamboley

In this blog, we'll discuss what some practitioners consider to be a pesky service: the Medicare wellness visit, also referred to as the Medicare annual wellness visit or AWV. For various reasons, the very phrase "Medicare wellness visit" can instill a sense of loathing and dread. Confusing and unclear language concerning Medicare wellness visit guidelines can leave practitioners confused, potentially resulting in missed income opportunities for practices and missed preventive care opportunities for patients. However, the downsides of skipping the Medicare wellness visit are worse: harm to your bottom line and potentially harm to your patients if they do not receive this essential service elsewhere.  

Created as part of the Affordable Care Act, the Medicare wellness visit carves out designated time between a patient and practitioner to discuss the patient's general health and wellbeing, presenting the opportunity to collaboratively plan appropriate wraparound care and identify preventive services the patient might be eligible for and benefit from. Topics such as general health, chronic illness, risk of injuries and functional abilities, behavioral and cognitive health, and opportunities to discuss advanced care planning help create an open line of communication between the patient and provider. This encourages patients to become more active participants in their health and compliant with treatment recommendations. 

For practitioners, the Medicare wellness visit offers a generous reimbursement, yet participation rates remain low. According to AJMC, only 16% of eligible beneficiaries received their Medicare wellness visit in 2014 — a modest increase since it's induction in 2011. This means there is a considerable opportunity for practices to furnish this service and reap its rewards. To effectively and compliantly do so requires understanding the Medicare wellness visit process and Medicare wellness visit guidelines, which are discussed below, and implementing solutions that can help streamline the process and eliminate the barriers keeping practices from adding or expanding the service.  

How does the Medicare wellness visit work? 

Before we can discuss the Medicare wellness visit, we need to first provide an overview of the initial preventive physical examination (IPPE). Medicare beneficiaries are eligible for their IPPE within the first 12 months of enrollment with Medicare Part B. The IPPE should be used to review the patient's medical and social health history and provides the perfect opportunity to review and educate patients on preventive services.  

After the first 12 months of enrollment in Medicare Part B, beneficiaries are then eligible for their Medicare wellness visit and may receive recurring wellness visits once every 12 months. The IPPE and Medicare wellness visit can be conducted by physicians, nurse practitioners, clinical nurse specialists, or a physician assistant, with all other tasks, such as pre-visit outreach, being conducted by clinic staff. Also worth noting: Due to COVID-19 exposure concerns, a federal waiver permits practitioners to conduct the Medicare wellness visit over the telephone as long as certain specifications are met.  

Breaking down the Medicare wellness visit guidelines  

Here are nine of the steps to take to properly furnish the Medicare wellness visit. 

1. Perform a health risk assessment 

This piece of the Medicare wellness visit is simply collecting pertinent patient information. Since this component can be time-consuming if completed during the visit, it's helpful to encourage patients to gather the necessary information prior to their appointments. Collecting this information during a pre-visit outreach call is another way to mitigate the practitioner's time required for the actual in-person visit. Topics covered in the health risk assessment should include patient demographics, self-assessment of health status, psychosocial risks, behavioral risks, and identifying the patient's activities of daily living, such as dressing, bathing, shopping, and medication and money management.  

2. Update the beneficiary's medical and family history 

The collection of medical and family history information can also be part of the pre-visit outreach. This piece of the wellness visit includes updating relevant family health history information, including hereditary issues the patient may be at risk for as well as the patient's past medical history.  

3. Create a list of the patient's current healthcare providers and suppliers of healthcare 

During the pre-visit outreach, create a list of all the specialists the patient sees, the pharmacies the patient uses, and any durable medical equipment vendors the patient purchases medical equipment from.  

4. Conduct a general health assessment 

This component of the Medicare wellness visit includes collecting and documenting information about the patient's height, weight, blood pressure, and all other indicators of general health and wellbeing. 

5. Evaluate and document the patient's risk factors for depression and any past experiences with depression or other mood disorders

Discussions about mental health are never easy, but seniors have some of the highest incidences of depression, so this component should not be overlooked. The PHQ-9 is a great tool for this part of the evaluation. The PHQ-9 can be filled out by the patient or patient representative prior to the appointment and then reviewed and discussed during the visit. 

6. Review the patient's functional ability and level of safety 

Can the patient still drive? Can he/she get to the store to purchase necessities? Can he/she handle their personal finances appropriately? Is the patient at an increased risk of falling? These are all important topics to address and document during this component of the Medicare wellness visit. 

7. Update the patient's list of risk factors 

This part of the Medicare wellness visit will help identify which preventive services and screenings the patient may need. The list should include mental health conditions, substance use disorders (e.g., tobacco, alcohol, legal and illegal drugs), and any cognitive concerns or impairments. For any identified risk factors, treatment recommendations should be provided to the patient and documented in the visit notes. 

8. Provide the patient with a plan based on the Medicare wellness visit results 

This is the opportunity to develop a game plan with the patient based upon issues identified during the visit. The patient should receive a written screening schedule that outlines all the appropriate screenings the patient is due for currently and those that will become due over the next 5-10 years.  

9. Offer, at the patient's discretion, the opportunity to discuss advanced care planning services 

While not the easiest topic to broach, the subject of end-of-life preferences is an important conversation to have during the Medicare wellness visit. If advanced care planning isn't a service typically provided by your practice, refer the patient to a physician or other qualified health care professional who can help.  

A win for patients, a win for practitioners 

The Medicare wellness visit is beneficial for both patients and practitioners. Patients who participate in annual wellness visits often have higher levels of trust and confidence in their provider and enjoy more open lines of communication with their healthcare team. Patient compliance and treatment adherence rates increase because patients have a better understanding of their health status and future health goals. Lastly, patients who participate in the Medicare wellness visit become better connected to beneficial health services — with no out-of-pocket expenses since the Medicare wellness visit is covered fully every calendar year.  

For practitioners, the Medicare wellness visit can generate significant income for the practice, with each visit reimbursement averaging around $260. Software platforms, such as Prevounce, make it simple for practitioners to furnish, document, and bill for the visit and those preventive services provided in conjunction.  

The United States currently has more than 61 million Medicare beneficiaries, and that number is expected to grow to 95 million by 2060. Between the ever-growing Medicare-eligible population and generous reimbursement, the Medicare wellness visit is a great way to capture and grow continuous income for your practice for years to come.

Annual Wellness Visit Toolkit

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