Medicare Physical Article --> How to Conduct a Welcome to Medicare Visit

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April 2005 (table of contents <http://www.aafp.org/fpm/20050400/> )

Vol. 12, No. 4

http://www.aafp.org/fpm/20050400/27howt.html

Getting Paid

How to Conduct a " Welcome to Medicare " Visit

You and your patient have a lot of ground to cover. Here's one way to get it

all done.

Randall O. Card, MD, FAAFP

<http://www.aafp.org/fpmquiz/> CME Covered in FPM Quiz

<http://www.aafp.org/fpm/20050400/27howt.html#box_d> Tool Tool inside

The new Welcome to Medicare exam revolves around preventive health care,

something family physicians have always incorporated into their practice.

But as you work out your routine for performing these visits, you might need

to reframe your thinking about what constitutes a physical exam.

The new Medicare exam includes seven elements, and they add up to a patient

encounter that is as much of a conversation as it is a physical exam. Making

sure you cover all of the required elements in the allotted time takes a

well-planned routine. If you haven't already developed such a routine, this

article suggests some time-saving strategies. It is followed by an encounter

form <http://www.aafp.org/fpm/20050400/27howt.html#box_d> that will help

you to ensure all elements of the initial preventive physical exam are

completed. The form also should help you meet evaluation and management

(E/M) documentation requirements.

The essential elements

As part of the Medicare Modernization Act (MMA), Medicare beneficiaries

whose Part B coverage began after Jan. 1, 2005, and who are within six

months of the effective date of their coverage are eligible for one initial

preventive physical exam. The exam focuses on identifying modifiable risk

factors for medical conditions that frequently affect the elderly, as well

as education, counseling and referral for Medicare-covered preventive

services.

Here are the seven required elements:

1. Review of comprehensive medical and social history. The purpose of this

element is to identify modifiable risk factors for disease.

You might need to reframe your thinking about

what constitutes a physical exam.

The medical history component should include illnesses, hospitalizations,

surgeries, injuries, allergies, medications, supplements and vitamins.

Social issues to address include alcohol, tobacco and illicit drug use;

diet; and physical activities. The family history is performed to identify

hereditary diseases or diseases that otherwise place the patient at

increased risk for disease.

BILLING FOR A WELCOME TO MEDICARE VISIT

Along with settling on a new routine for the Welcome to Medicare exam,

you'll also want to make sure you understand its billing requirements.

For a complete overview, see " New Year, New

<http://www.aafp.org/fpm/20050200/15newy.html> Medicare Benefits, " FPM,

February 2005, page 15.

2. Review of risk factors for depression. This next element involves

identifying depression and other mood disorders. The Centers for Medicare &

Medicaid Services (CMS) does not recommend a specific depression screening

tool. Instead, CMS states that you " may select from various available

standardized screening tests designed for this purpose. " 1

<http://www.aafp.org/fpm/20050400/27howt.html#refs>

Many standardized depression screening tools are too cumbersome to use in a

short office visit. One quick technique recommended by the U.S. Preventive

Services Task Force (USPSTF) involves asking two questions: " Over the past

two weeks, have you felt down, depressed or hopeless? " and " Over the past

two weeks, have you felt little interest or pleasure in doing things? " An

affirmative answer to either may be as effective as more detailed

instruments in identifying a patient who needs further evaluation for

depression.2 <http://www.aafp.org/fpm/20050400/27howt.html#refs>

3. Review of functional ability and level of safety. You have a lot of

leeway with this element, which requires you to evaluate your patient's

hearing, activities of daily living, functional ability and level of safety.

As with the depression screening, CMS accepts any appropriate screening test

that is recognized by national medical professional groups.

PREVENTIVE SERVICES BY MEDICARE PART B

* Pneumococcal, influenza and hepatitis B vaccines

* Screening mammography

* Screening Pap smear/pelvic exam

* Prostate cancer screening

* Colorectal cancer screening

* Diabetes outpatient self-management training services

* Bone mass measurements

* Screening for glaucoma

* Medical nutritional therapy for individuals with diabetes or renal disease

* Cardiovascular screening blood tests

* Diabetes screening tests

For determining fall risk, I recommend following the American Geriatrics

Society's (AGS) clinical guidelines. According to the AGS, there are two

tests that should trigger further patient evaluation: if your patient

previously has received treatment for a fall, or if your patient takes

longer than 30 seconds for an " Up & Go " test.3

<http://www.aafp.org/fpm/20050400/27howt.html#refs>

The timed Up & Go test involves having the patient stand up from a chair,

walk three meters, turn around, walk back to the chair and sit back down. If

the patient takes longer then 30 seconds or seems unsteady, the test is

considered positive for increased fall risk.

To identify functional challenges, the CDC advises screening your patients

by inquiring about their instrumental activities of daily living (IADLs).

This involves asking patients about troubles using a phone, using

transportation, grocery shopping, preparing meals, doing housework, doing

laundry, taking medications and managing money. Any limitation to their

IADLs that you identify as being caused by a chronic condition warrants

further evaluation.

You should refine how your office handles this new Medicare benefit

before patients are even in the exam room.

While functional assessments have been researched extensively, less evidence

exists for home safety screening. The CDC recommends that elderly patients

improve home safety by removing tripping hazards in walkways, using non-slip

mats in bathtubs and showers, placing grab bars next to the toilet and

shower, placing handrails on both sides of a stairway and improving home

lighting. It seems reasonable to question patients about these items during

the initial preventive physical exam.

For the hearing evaluation, I plan to follow the USPSTF's recommendation to

simply question patients about their hearing function. There are, of course,

more elaborate testing methods, but the USPSTF found insufficient evidence

to recommend for or against them.4

<http://www.aafp.org/fpm/20050400/27howt.html#refs>

Your screening for depression risk, functional ability and level of safety

should be accompanied by further evaluation, including a full diagnostic

workup, for any patients with positive responses. The workup can be

performed in conjunction with the initial preventive physical exam, or the

patient can be further evaluated later. CMS will allow a level-one or

level-two E/M code with a -25 modifier attached to be billed with the

initial preventive physical exam. If you conclude that the depression or

fall risk does not warrant immediate care but will require a level-three or

higher E/M service, it might be prudent to perform the full workup at a

later date.

4. A focused physical exam. This should be an extremely focused physical

exam. Height, weight, blood pressure and visual acuity are the only required

components. No specific vision tests are mandated, but using the Snellen

chart is appropriate.

5. Performance and interpretation of an electrocardiogram. Some offices have

the capacity to handle this, and others will need to send the patient to

another facility. Either way, the ECG results need to be incorporated into

your patient's medical record to complete the initial preventive physical

exam.

If the patient is sent to another facility for the ECG, the order must read

" ECG as part of the Welcome to Medicare Physical, codes G0366-G0368. "

Medicare has instructed that physicians must order the ECG in a manner that

helps to prevent use of codes for ECGs not related to the initial preventive

physical exam.

6. Brief education, counseling and referral to address any pertinent health

issues identified during the first five elements of the exam. CMS expects

the amount of time required for this step to vary depending on the problems

that you discovered in the first five elements.

7. Brief education, counseling and referral, with maintenance of a written

plan (such as a checklist), regarding separate preventive care services

covered by Medicare Part B. There are now 11 preventive services authorized

under Medicare Part B. Coverage for the two newest ones, cardiovascular

disease screening and diabetes screening, became effective on Jan. 1, 2005.

For the full list, see " Preventive services covered by Medicare Part B "

above <http://www.aafp.org/fpm/20050400/27howt.html#box_b> .

It is important that you thoroughly understand Medicare's policy on these

services before counseling your patient. Some services are covered at 100

percent of the Medicare allowable charge, and some services are covered at

80 percent of the Medicare allowable charge. In addition, some of the

services are covered only if medically indicated.

Kent J. , AAFP's manager for health care and delivery systems, has

written two FPM articles that cover these Part B services. " Another Ounce of

<http://www.aafp.org/fpm/20021100/25anot.html> Prevention "

(November/December 2002, page 25) covers most of the benefits, and " New

Year, New <http://www.aafp.org/fpm/20050200/15newy.html> Medicare

Benefits " (February 2005, page 15) summarizes the two new ones. (These

articles are available online at http://www.aafp.org/fpm.)

Put it in writing

A checklist or another method of documentation indicating that the seven

elements of the initial preventive physical exam have been addressed must be

maintained in the patient record. The form below

<http://www.aafp.org/fpm/20050400/27howt.html#box_d> has been designed to

do that.

In addition, you are required to give your patient a written plan for

obtaining the appropriate preventive services. I suggest that you make a

copy of the form's second page to give to the patient at the exam's

conclusion. If you want to get fancy, you could design a similar form with a

duplicate page two, allowing you to keep the original and give the carbon

copy to the patient.

PREPRINTED HANDOUTS

Familydoctor.org has patient education materials regarding many of the

preventive health issues covered in an initial preventive physical exam.

Breast cancer screening

http://familydoctor.org/018.xml

Cardiovascular blood tests

http://familydoctor.org/029.xml

Colon cancer screening

http://familydoctor.org/556.xml

Diabetes screening

http://familydoctor.org/327.xml

Glaucoma

http://familydoctor.org/216.xml

Osteoporosis

http://familydoctor.org/136.xml

Prostate cancer screening

http://familydoctor.org/361.xml

Screening Pap/pelvic

http://familydoctor.org/138.xml

A timed exchange

Over time, you will become more adept at completing the initial preventive

physical exam in a reasonable period. CMS considers the

physician/non-physician provider time component of the initial preventive

physical exam to be equivalent to a 30-minute 99203 (new patient,

level-three E/M code).

To speed the process along, you could use preprinted patient education

materials to counsel your patient. For some specific examples available on

Familydoctor.org <http://www.familydoctor.org/> , AAFP's patient education

Web site, see " Preprinted handouts. " It would also be helpful to ask your

patients to bring to the visit the " Guide to Medicare's Preventive

Services, " which each new beneficiary is receiving in their Welcome to

Medicare package. It can be viewed or downloaded at

http://www.medicare.gov/publications/pubs/pdf/10110.pdf.

As you perfect your Welcome to Medicare exam routine, you should also refine

how your office handles this new Medicare benefit before patients are even

in the exam room. Identify new Medicare-eligible patients. Schedule the

patients in a timely manner. Perform some of the screening before the

face-to-face encounter.

MEDICARE INITIAL PREVENTIVE PHYSICAL EXAMINATION ENCOUNTER FORM

This form was updated in 2007 to reflect changes to Medicare's covered

services. You can download the updated

<http://www.aafp.org/fpm/20060900/medicarepreventiveexam.pdf> encounter form

as a PDF here.

image <http://www.aafp.org/fpm/20050400/27howt_f1.gif>

Create two copies of this page: one for your charts and one to give to your

patient.

image <http://www.aafp.org/fpm/20050400/27howt_f2.gif>

_____

Developed by Randall O. Card, MD, FAAFP, Marquette General Hospital,

Marquette, Mich., and , CPC, AAFP Coding & Compliance

Specialist. Copyright © 2005 American Academy of Family Physicians.

Physicians may photocopy or adapt for use in their own practices; all other

rights reserved. Card RO. How to conduct a " Welcome to Medicare " visit. Fam

Pract Manag. April 2005:27-32; http://www.aafp.org/fpm/20050400/27howt.html.

The initial preventive physical exam is an opportunity for you and your

newly enrolled Medicare patients to start thinking about Medicare-covered

preventive services. Effective, efficient use of the initial preventive

physical exam requires physicians and non-physician providers to understand

the specific components of the initial preventive physical exam. A systems

approach to identifying, educating and counseling patients regarding

Medicare-covered preventive services may improve patient health and help

physicians deliver the initial preventive physical exam in a financially

sound manner. <http://www.aafp.org/fpm/20050400/images/end_bug.gif>

Send comments to fpmedit@....

1. CMS Manual System. Pub. 100-04 Medicare claims processing. Dec. 22, 2004.

Available at: http://www.cms.hhs.gov/manuals/pm_trans/R417CP.pdf. Accessed

March 15, 2005.

2. U.S. Preventive Services Task Force. Screening for depression:

recommendations and rationale. Ann Intern Med. 2002;136:760-764.

3. Kenny RA, stein LZ, FC, et al. Guideline for the prevention

of falls in older persons. J Am Geriatr Soc. 2001;49:664-672.

4. U.S. Preventive Services Task Force. Screening for hearing impairment.

In: Guide to clinical preventive services: a report of the U.S. Preventive

Services Task Force. 2nd ed. Baltimore: & Wilkins; 1996:393-405.

Dr. Card is associate director of the Family Practice Residency Program at

Marquette General Hospital in Marquette, Mich. He thanks Olson and

Elliott, MD, for their help on this article. Conflicts of interest:

none reported.