More than 1.3 million Medicare patients have taken advantage of the annual wellness visit (AWV) benefit since it was introduced in January 2011 as a result of the Affordable Care Act, according to data released in July by the U.S. Department of Health & Human Services. Providing these additional visits has caused an increased burden to the entire medical team. It can be challenging and frustrating for physicians to provide and document the extensive list of required elements in a 20 or 30 minute visit. In addition, misconceptions about the purpose and coverage requirements of the AWV, the Welcome to Medicare visit, and other Medicare wellness exams are common among both patients and providers. In our practice, the majority of Medicare wellness visits lacked proper documentation. Patients sometimes had to return to the office to complete the visit before it could be billed, adversely affecting patient satisfaction, access, and physician productivity.

To address these problems, our group developed and implemented a best practice model that establishes a streamlined workflow, increases efficiency, uses an electronic health record (EHR), and satisfies all required elements using a team-based, collaborative approach. This article will describe the key interventions that were instrumental in our success: scheduling protocols, a two-part visit that begins with a nursing “previsit,” and billing and coding policies and procedures. Whether you adopt a similar model or create your own, it is important to take a systematic, organized approach to scheduling, providing, and billing for these complex services.

A team approach

We began this project by forming a core interdisciplinary team of leaders. Involving experts from all areas of practice helped us create an efficient workflow to meet the challenges of the AWV and other Medicare wellness visits. Our team included a physician, clinical and clerical staff, a licensed vocational nurse (LVN), our office manager, and coding staff. We made time for one-hour meetings every two weeks for two months. In addition, the nonphysician staff has routine monthly meetings to discuss site operations; Medicare wellness visits are always a topic during these discussions.

We began our work by ensuring that our team understood the basic differences between AWVs and other Medicare wellness visits. Developing a shared understanding of terms and concepts gave us a foundation on which to set goals, identify challenges, and develop action plans.

Scheduling protocols

Defining relevant terms and concepts was especially important in training our schedulers to clarify patients' needs and expectations when they call for appointments, educate patients as needed, and schedule them appropriately. A resource similar to the one shown below proved to be valuable to schedulers, who play an important role in managing the increased demand for wellness visits.

A two-part visit

To enhance our efficiency, we reallocated nursing resources to complete some elements of these visits. We expanded the role of an LVN whose primary responsibilities were to perform procedures such as pulmonary function tests, ankle-brachial index exams, and wound care in our nurse clinic, to include obtaining and documenting some of the required elements during a 30-minute, same-day previsit. Cross-trained medical assistants (MAs) fill in when our LVN is unavailable. Smaller practices may find it more practical to use an MA in the nursing role routinely. The nurse previsit enables the physician to focus on those aspects of the visit that require a physician's knowledge and skills.

The day before the appointment, the LVN reviews the patient's chart and asks the physician or provider for any special instructions or orders, such as the need for an ECG or vaccinations. At the previsit, the LVN performs the following duties before handing the patient off to the physician or provider:

• Start a note using the EHR template for Medicare wellness visits,

• Obtain information to complete a health risk assessment,

• Review, update, and record the patient's past medical/surgical/family/social history and diet information,

• Reconcile the medication list,

• Conduct a brief depression and cognitive impairment assessment, then complete a PHQ-9 depression screening questionnaire and Mini Mental Status Exam if indicated,

• Complete a functional ability assessment,

• Obtain and record vital signs,

• Perform visual acuity screening,

• Obtain an ECG if ordered by the provider; a screening ECG performed as the result of a referral from a Welcome to Medicare visit is a once-in-a-lifetime benefit, but an ECG performed in connection with an AWV may be subject to deductible/coinsurance/copay.

• Conduct a brief hearing assessment, then perform basic audiometric screening if indicated (although it is not required by Medicare, we feel that audiometric screening provides the best objective assessment; it is not separately billed),

• Print the previsit note and highlight any items of potential concern for the physician or provider,

• Provide Advance Directive and Physician Orders for Life Sustaining Treatment forms for patient if indicated,

• Escort the patient to see the physician or provider, and deliver the printed note.

The LVN follows a prescribed workflow in order to complete all required elements within the allotted time. Patients seem to appreciate the one-on-one experience with our nurse, and this workflow allows the physician or provider and his or her MA to be more productive.

The physician or provider then completes the remaining elements needed to satisfy the Medicare requirements:

• Review, extend as appropriate, and sign off on the history obtained by the LVN,

• Follow up on any concerns noted by the LVN,

• Perform a focused physical exam, not a comprehensive, “head-to-toe” exam,

• Review the completed screening and test results and make any indicated final diagnosis,

• Discuss end-of-life planning if needed,

• Provide education, counseling, and referrals based on history and exam,

• Using the EHR, complete a brief written plan, which includes needed screenings and other preventive services covered as separate Medicare Part B benefits,

• Print a patient summary, which includes patient demographics, assessed problems, vital signs, medication list, and the documented plan, and give this to the patient to take home.

Billing and coding policies and procedures

The previsit is billed as a no-charge nurse visit. However, any services performed by the LVN during this visit that are not covered as part of the Medicare wellness visit are billed under the physician or provider's name. These charges are submitted by the physician or provider after review.

Physicians can bill wellness visit codes in addition to other preventive services. The relevant codes for the wellness visits and other Medicare preventive services that might realistically be provided in connection with the Medicare wellness visit are shown in the table below, along with relative-value units and payment amounts. With an efficient workflow, providing covered screening services at the same time as the Medicare wellness visit can maximize reimbursements. For example, a female smoker who is being seen for a Welcome to Medicare visit can also have tobacco-use counseling, depression screening, and a well-woman exam, maximizing the value of the appointment to the patient while increasing total RVUs from 3.64 to 4.67 and payment from $155.89 to $224.31 (Medicare allowable rates). Note that these figures do not include associated labs or diagnostic studies. See a complete list of Medicare-covered services, their codes, and coverage details. Reimbursement amounts can be looked up using the Medicare Physician Fee Schedule Lookup.

If the patient wants to have the physician or provider evaluate and manage medical problems in addition to the wellness visit, the appropriate problem-oriented office visit code (e.g., 99213 or 99214) with modifier 25 may be billed if the services are documented.

It is important to remember that routine physicals (comprehensive, “head-to-toe” exams) are not covered by traditional Medicare. If a Medicare patient is being seen for a wellness visit and requests a routine physical, the patient must sign an advance beneficiary notice (ABN) form, because the patient will be responsible for charges associated with the noncovered service (99387 or 99397). The physician or provider must document that the service was provided at the patient's request and that an ABN was obtained.

Continuing improvements

Before we implemented this model, physicians were spending an hour or more on average to satisfactorily complete all the required elements of Medicare wellness visits. Our project team monitored several metrics over two months to evaluate the effect of our interventions. The previsit averaged 30 minutes, and the physician or provider visit averaged 15 to 20 minutes. All required elements were satisfactorily met, there were no billing and coding problems, and only minimal issues surfaced with patient scheduling. Because we achieved dramatic improvements in a relatively short time, this workflow was presented at physician leadership meetings and to our organization's administrative leadership team. The decision was made to begin implementing this workflow at our 18 sites.

We continue to find ways to improve our model. A few previsits extended beyond the 30-minute schedule because of language barriers and patient late arrivals. We implemented a “flag” system in our scheduling software to allow schedulers to indicate that interpreter services would be required so that these arrangements could be made before the visit. We also cross-trained MAs to complete elements that were not obtained during the previsit. When we discovered that our automated appointment reminder service was calling patients to remind them of their physician or provider appointments but not their previsit appointment with the LVN, we discontinued the service and now have staff make these calls. Finally, to create more appointment slots for previsits, we eliminated “blood pressure check” visits with the LVN and instead schedule them for the provider's MA to perform. We are regularly administering competency exams to all administrative and medical staff to ensure they can fulfill their duties under the practice model.

Final thoughts

With the ever-changing health care climate and added regulations under the Affordable Care Act, it is important to explore methods that maximize office efficiency. Physicians and providers cannot do it alone and must collaborate with the entire medical team to continuously improve and refine their practice model and office workflows. With the right amount of preparation, teamwork, and vision, Medicare wellness visits can be a valuable medical service that fulfills the purpose of providing optimum preventive care without placing an additional time burden on physicians and providers.