Abstract
As diabetes care and education specialists seek to broaden their reach in primary care, a preventive visit type presents an opportunity to demonstrate value and generate revenue. The Medicare Annual Wellness Visit (AWV) allows beneficiaries (generally senior citizens) to work together with medical professionals to proactively identify and address their potential health risks. When diabetes care and education specialists facilitate these visits, they may refer appropriate beneficiaries to diabetes prevention programs or self-management education and support services (DSMES), thus building participation in these effective and underutilized services. AWVs offer annual reimbursement and also revenue-generating opportunities in related services (e.g., medical nutrition therapy, CGM) for primary care practices and for providers.
In its Vision for the Specialty, the Association of Diabetes Care and Education Specialists (ADCES) recognizes the broad expertise of diabetes care and education specialists and encourages them to practice at the highest level allowed by individual licenses. The AWV presents an opportunity to do just that in primary care settings. Diabetes care and education specialists evaluate individuals for clinical and self-management needs and work collaboratively with them to craft practical solutions. Primary care physicians and qualified nonphysician practitioners can direct bill Medicare Part B and receive the reimbursement and the Relative Value Units (RVU) for these visits while directly supervising the medical professionals who perform them. To meet the direct supervision requirement, the physician or nonphysician practitioner who is billing Medicare for the AWV must be on site and immediately available to provide assistance and direction throughout the time the visit is being furnished, but he or she does not have to be present in the room.
When the diabetes care and education specialist performs the AWV, physicians can better spend their time caring for sick individuals who need medical care instead of those eligible for preventive screenings. Reimbursement for AWVs may provide funding for additional diabetes care and education specialist resources in the practice. AWVs utilize electronic medical record information to leverage technology and provide better care coordination, a pillar of the ADCES Vision. Medical professionals screen each beneficiary for behavioral health and related conditions and promote person-centered care by actively engaging the beneficiary in self-care and treatment to improve health and well-being. These visits serve as additional touch points between the practice and the person with diabetes to provide ongoing support and improve engagement.
AWVs utilize electronic medical record information to leverage technology and provide better care coordination, a pillar of the ADCES Vision.
Components of the Medicare Annual Wellness Visit
The AWV is a health assessment and health care planning appointment. It is similar to the Welcome to Medicare Visit (WMV) or Initial Preventive Physical Exam (IPPE), a 1-time visit conducted in the first 12 months of the beneficiary’s enrollment in Medicare Part B. The AWV is an ongoing, every-12-month benefit starting after the first year of Part B enrollment.
The AWV includes a Health Risk Assessment (HRA) in which the individual takes an active role in his or her own health self-assessment. Ideally, it is conducted as a conversation between the beneficiary, a support person (if desired), and the medical professional. Areas discussed include psychosocial and behavioral risks, such as fall risk and cognitive impairment, and the ability to independently complete activities of daily living, including financial management, cooking, and shopping. A full description of the visit is available at cdc.gov/policy/hst/HRA/FrameworkForHRA.pdf. The information obtained from the HRA is used to collaboratively develop a Personalized Prevention Plan of Service (PPPS) with the beneficiary.
Elements of a Personalized Prevention Plan of Service Developed During a Medicare Wellness Visit
→ Health Risk Assessment results
→ Complete medical and family history
→ List of providers and suppliers that are regularly involved in the beneficiary’s medical care
→ Measurement of height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine physiological measurements
→ Detection of any possible cognitive impairment
→ Establishment of or update to a screening schedule for the next 5 to 10 years based on national standards and the beneficiary’s health status
→ List of risk factors and conditions for which prevention interventions are recommended or are underway and a list of treatment options and their associated risks and benefits
→ Personalized health advice and referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management or to community-based lifestyle interventions to reduce risk and promote health and wellness
Medicare Part B covers AWVs for eligible beneficiaries when performed by any of the following health care professionals:
Physician (doctor of medicine or osteopathy)
Qualified nonphysician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist)
Medical professional (health educator, registered dietitian, or other licensed practitioner) or a team of professionals directly supervised by a physician or qualified nonphysician practitioner who is a Medicare Part B provider (direct supervision is defined as being in the office building and available to provide immediate assistance if needed during the wellness visit.)
The inclusion of “medical professional” on the list of qualified providers presents an opportunity for diabetes care and education specialists to perform the AWV, assess the individual’s risk for or self-management of diabetes and other chronic conditions, and develop a PPPS with the beneficiary to proactively address identified health issues.
The inclusion of “medical professional” on the list of qualified providers presents an opportunity for DCES to perform the AWV.
The AWV is billed by the supervising physician or qualified nonphysician practitioner. These visits are billed using Medicare-assigned procedure codes. The 2019 codes and national geographically unadjusted reimbursement rates are shown in Table 1. The CMS Physician Fee Schedule is updated annually.
Billing Procedure Codes for Medicare Annual Wellness Visit (AWVs) and Related Services
Creating a New Visit Type
We work with Saratoga Hospital’s primary care practice network and identified an opportunity to improve the preventive care of Medicare beneficiaries through a collaboration between diabetes care and education specialists (RNs and RDs in this case) and practice providers to provide AWVs. While researching the requirements for this service, we determined that there are 9,000 eligible Medicare Part B beneficiaries across the Saratoga Hospital system and that only 100 AWVs were completed in 2017. These numbers reflect a lost reimbursement potential of about $900,000 in addition to the financial incentives that payers provide to organizations and member participants to complete AWVs.
After reviewing the required program components, we developed standardized processes and program components for delivering AWVs. The director of nursing practice discussed the opportunities with the leadership team of the medical group, developed a business plan for the project, and with much persistence, worked to secure administrative support, though with limited success. This lack of support by leadership and primary care providers, largely due to competing priorities, limited our ability to implement the project. Despite this challenge, we have made progress as follows:
The diabetes care and education specialist team was trained to complete the visit components.
Front office and clinical staffs were trained on the process and the importance of clearly communicating the purpose of the AWV to eligible beneficiaries.
A standardized scheduling process and documentation templates are currently under development.
We continue to identify program components to address before the pilot begins. We continue to advocate for leadership and provider support and are evaluating practices with the goal of beginning a small pilot project in 2020.
Important Considerations
Although this project has not yet started, we are gaining valuable insight into how to develop and implement this primary care service (Figure 1). Some important lessons we have learned include the following:
Obtain buy-in and commitment of senior leadership for successful implementation. Take every opportunity at every level of the organization to discuss the number of Medicare beneficiaries in the health care system, amount of reimbursement to be gained by implementing AWVs and via related services stemming from these visits, and additional financial incentives for meeting payers’ quality measures.
Engage a well-respected, committed physician champion. This is critical to the success of implementing a new visit type. Identifying a physician who is interested in offering AWVs but needs additional resources and a blueprint to do so is the best first step to take. We are still working on this essential component, which has slowed our ability to move forward.
Involve staff at all levels of the practice in the planning and development of this new visit type. Soliciting their feedback every step of the way fosters a sense of buy-in and ownership. For example, asking front desk staff to develop scripting language to use when discussing AWVs with potential participants and scheduling appointments since they will be responsible for these tasks informs them about the new services and provides feedback about how to explain it to clients in a clear and concise way.
Start small and gradually build on successes. Be sure to address “What’s in it for me?” with providers and staff.
As with any new project, don’t give up, and be persistent. Although our project is progressing slower than we had hoped, we are developing a plan to implement AWVs later this year.
Remember, helping Medicare beneficiaries live healthy, safe, and productive lives by offering all available Medicare benefits is the right thing to do.
Developing a Medicare wellness visit primary care service.
Start small and gradually build on successes. Be sure to address “What’s in it for me?” with providers and staff.
Conclusion
The AWV provides a unique opportunity for diabetes care and education specialists to demonstrate their value to primary care in a new and comprehensive way. In addition to creating a new revenue stream for each practice, AWVs allow providers to proactively develop plans to improve the health and well-being of Medicare beneficiaries, and they present an opportunity for diabetes care and education specialists to practice in a nontraditional role to support providers and patients. We are excited to bring AWVs to our practices, providers, and Medicare beneficiaries this year, and we look forward to a future of expanding possibilities for our specialty.
Footnotes
Lisa Hodgson, RD, CDN, CDCES, and Judith Carr, MS, RD, CDN, CDCES, are with Saratoga Hospital in Saratoga Springs, NY. Kimberly Spano, MSN, MEd, RN, NE-BC, is with Saratoga Hospital Medical Group in Saratoga Springs, NY.