SCGhealth Blog

Medicare patients still worse than others when it comes to getting preventive visits done

Tuesday, February 24, 2015

By Scott Kraft

More Medicare patients have taken advantage of covered annual preventive services since implementation of the Affordable Care Act (ACA), according to a recent study in the journal Health Affairs.

The study revealed that nearly 28 percent of Medicare fee-for-service patients at the Palo Alto Medical Foundation received annual preventive visits following the ACA, compared to 1.4 percent before. Despite this progress, the numbers still lag behind the 53 percent rate of Medicare Advantage patients and the 44 percent rate of patients aged 65-75 with private insurance.

The study concludes that one way to drive expanded use of Medicare’s annual preventive visits is to make the benefit better – after all, the ACA improved the benefit by making sure patients were able to get the annual preventive visit with no out-of-pocket expense.

It may not entirely be a question of money – our analysis shows that the RVUs for Medicare’s annual preventive visits are consistent with the CPT preventive services codes, though to be fair Medicare often pays a lower conversion factor than private insurance.

A key challenge may be that, despite an initial Medicare preventive visit being available since 2005 and an annual visit since 2011, these visits are still not well understood by patients and providers alike because they are fundamentally different from preventive physicals covered by most other insurance.

The biggest difference is that Medicare rules use these visits to drive the patient toward other screening and preventive visits covered by Medicare, such as colonoscopies and mammographies. This creates different requirements for collection of documentation, including which information is collected by the doctors versus the ancillary staff.

In addition, while the Medicare preventive visits require an examination of the patient, it is to the discretion of the practitioner as to which systems are examined. Much of the work of the Medicare preventive visit can be done by licensed practical nurses, though physicians often want to be involved in this element of patient care. A non-physician practitioner is able to do the entire service.

There are three different types of Medicare annual preventive visit:

  1. Initial Preventive Physical Exam (IPPE): This service must be given within the patient’s first 12 months of Medicare eligibility and is billed with code G0402. Payment is approximately $169, subject to regional adjustment.
  2. Initial Annual Wellness Visit (AWV): This is the initial annual wellness visit the patient receives after the IPPE, following the first 12 months of Medicare eligibility. The patient can receive this service any time after the first year of eligibility, but Medicare will pay for only one initial AWV in the patient’s lifetime. The payment is approximately $175.
  3. Subsequent Annual Wellness Visit (AWV): This is a subsequent annual wellness visit the patient may receive once annually after the first AWV. There must be at least 11 months in-between each AWV service a patient receives.

For each of the services, Medicare will waive the copayment and deductible so that the patient has no out-of-pocket expenses to pay.

Initial Preventive Physical Examination (IPPE)
As noted above this service must be given to a patient within his or her first 12 months of Medicare eligibility. Once 12 months have passed, the patient is no longer eligible for this service, but still may receive an initial AWV.

In order to bill an IPPE, the practice must document the patient’s medical and social history, risk factors for depression and other mood disorders and a review of the patient’s safety level and functional ability.

The practice must document the patient’s vital signs, including body mass index and a visual acuity screen. The patient has the option of getting end-of-life planning. Finally, the patient should be given education and counseling based on the findings of the exam, a referral for an ECG and other appropriate screenings covered by Medicare based on the patient’s eligibility.

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