Historically, the Centers for Medicare and Medicaid Services (CMS) have not paid for preventive care or for routine physical examinations.  But there are parts of the Accountable Care Act (ACA) which provide benefits which suggest that CMS is getting serious about Preventive Health Services which have the potential for moving us toward the fulfillment of the Triple Aim:  improved care (processes), improve health (outcomes) and decreased costs (sustainability). 

The ACA has made provision for the following Preventive Health Services at little or no cost to Medicare beneficiaries.  The new Intensive Behavioral Therapy codes for obesity and cardiovascular disease along with the Initial Preventive Physical Exam (IPPE), the Annual Wellness Visit Initial and Annual Wellness Visit Subsequent are significant advances in recognizing the value of preventive care and in recognizing the expertise of those who have the tools to provide those services. 

 Along with the Transitions of Care Management Codes which have been published this year, these preventive codes encourage the “right stuff” in primary healthcare delivery.   SETMA is determined to support and to promote these efforts by utilizing them in our practice.   The key to these codes is that there is no deductible and CMS pays the provider for the full allowable benefit. This is a savings to patients and it is also a revenue benefit to the healthcare provider.  The payment for the IPPE is approximately $159 with no cost to the patient.  If a screening EKG and/or screening abdominal ultrasound is warranted and ordered at this time, the fee is paid in addition to the IPPE fee and it is paid without deductible, also. 

One of the difficulties of these benefits is for a provider to remember who is eligible to receive this benefit.  In order to facilitate the use of these codes and to provide a no-cost benefit to our patients, SETMA has deployed an electronic means of alerting the provider to the fact that the patient qualifies for this benefit. 

Outlined in green below, there are three preventive-care, wellness visit codes authorized by CMS.  They differ by when they are allowed to be performed and by the fact that in the case of the IPPE an EKG and an Abdominal Ultrasound can be ordered.  The code descriptions are:

• G0402 Initial Preventive Physical Examination (IPPE)  (Also called the Welcome to Medicare Preventive Visit )
• G0438 Annual Wellness Visit, Initial (AWV) Annual wellness visit, including a personalized prevention plan of service (PPPS), first visit.
• G0439 Annual Wellness Visit, Subsequent (AWV) Annual Wellness visit, including a personalized prevention plan of service (PPPS), subsequent visit. Annual Wellness Visits can be for either new or established patients as the code does not differentiate. The initial AWV, G0438, is performed on patients that have been enrolled with Medicare for more than one year.

The G0402 code denotes the Welcome to Medicare Visit (also called the Initial Preventive Physical Exam (IPPE).  It must be performed within one year of becoming eligible for Medicare and it is a once in the patient’s life-time benefit.  It is not for a routine physical examination and does not provide for payment of laboratory services except a screening EKG and, when the patient is qualified, an Abdominal Ultrasound for screening for an abdominal aortic aneurysm.  There are five codes related to the IPPE which are:

• G0402 Initial Preventive Physical Examination (Welcome to Medicare Preventive Visit )
• G0403 EKG with interpretation and report, performed as a screening for the IPPE
• G0404 EKG without interpretation and report
• G0405 EKG interpretation and report only
• G0389 Abdominal Ultrasound - once in a lifetime benefit - deductible waived, must meet criteria for screening (see below)

Just above the three codes is a button entitled Eligibility (outlined in green below). 

When that Eligibility button is clicked, the Medicare Preventive Exam template appears. On this template all the elements of the three preventive care examinations appear.  In order to bill for any of the Medicare Preventive codes, all of the elements listed on this template must be fulfilled.  Until they are, if you click the Calculate Code Eligibility button, you will be informed that there is no code for which you can bill.

When any of the required elements are not fulfilled, they will appear in red as above.  In order to fulfill an incomplete element of the exam (those in red), simply click on the “Click to Complete” button to the right of each element which has not been met.   You will be taken to the place in the EMR where that evaluation can be completed and documented.  You will then be returned to the above template.  Once all of the elements are fulfilled - see the template below - all will turn black.

When you deploy the “Click to Complete” button next to the “visual acuity” element of the Medicare Preventive exam, you are taken to the template in SETMA’s EMR where the visual acuity is documented.  See below in green.

Once you document the visual acuity, click the “return” button at the top right of the template.

This takes you right back to the Medicare Preventive Exams template and now you see that the element in the exam - visual acuity - which was red is now black.

At this point, you click the “Calculate Code Eligibility” which is shown on the following template outlined in green. 

When the resulting eligibility code is an Annual Wellness Visit Initial (G0438) or an Annual Wellness Visit Subsequent (G0439), the following template will appear with the eligible code outlined in green.

At this point, click “OK.”  This action closes the Medicare Preventive Exam pop-up and the E&M template appears.

With this tool deployed in SETMA’s EMR, every patient who is eligible for this service will receive it.  It is believed by CMS and SETMA that this will improve care, improve health and will lower cost of care.