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BCA’s Medicare Preventive Services Audit Tool

BCA’s Medicare Preventive Services Audit Tool

Welcome to Medicare Visit (IPPE)

Medicare Annual Wellness Visits (AWV)

Advanced Care Planning (ACP) and Other Medicare Preventive Services

Welcome to Medicare Visit (IPPE) G0402: RVU W=2.6/Total = 4.92: National=$166.73 (Dx Z00.0X +others)
Available to the patient once (1) per lifetime no later than the first 12 months after Medicare benefits eligibility date

  1. [ ] Emphasis on relevant medical, family, social history (eg current meds, diet, activities, illegal drug use)
  2. [ ] Review patient’s potential depression risk factors (experiences w/depression or other mood disorders)
  3. [ ] Review functional ability, level of safety; hearing impairment, ADLs, fall risk, home safety
  4. [ ] Exam: Height, Weight, blood pressure , BMI, visual acuity screening, and other exam as needed
  5. [ ] End-of-life planning, on patient (and clinician) agreement; if not, so state.
  6. [ ] Review current opioid prescriptions (for patients with a current RX): pain evaluated, offer non-opioid options.
  7. [ ] Screen for potential substance use disorders (SUDs): Review risk factors and refer as appropriate.
  8. [ ] Educate, counsel, and refer appropriately based on findings of previous components
  9. [ ] Education, counsel & refer for other preventive services. Provide patient with a written checklist

Initial Annual Wellness Visit G0438: RVU Wk=2.6/Total = 4.91: National=$166.39 (Dx Z00.0X +others)
Available to the patient once (1) per lifetime after the first 12 months of Medicare benefits eligibility date

  1. [ ] Patient-generated Health Risk Assessment (HRA) (filled out by patient)
  2. [ ] Medical events of self/family including hereditary conditions increasing risk. Use of or exposure to meds & supplements.
  3. [ ] Establish list of current providers/suppliers that regularly provide medical and behavioral healthcare
  4. [ ] Measure (Exam): Height, Weight, BMI, blood pressure +other exam as needed per history/clinical judgment
  5. [ ] Detect any cognitive impairment: consider health disparities, chronic conditions +other factors that increase risk
  6. [ ] Review potential risk factors for depression ,including current or past experiences with depressive disorders
  7. [ ] Review functional ability, level of safety; ADLs, fall risk, hearing impairment, home safety
  8. [ ] Establish written screening schedule for next 5-10 years based on USPSTF, ACIP, pt’s HRA, health status
  9. [ ] Establish list of risk factors/conditions for which interventions are underway or recommended.
  10. [ ] Advise, educate and referral aimed at reducing health risks; fall prevention, nutrition, nicotine use.
  11. [ ] Provide Advance Care Planning (ACP) services at patient’s discretion
  12. [ ] Review current opioid prescriptions (for patients with a current RX): pain evaluated, offer non-opioid options.
  13. [ ] Screen for potential substance use disorders (SUDs): Review risk factors and refer as appropriate.

Subsequent Annual Wellness Visits G0439: RVU Wk=1.92/Total = 3.84: National=$130.13 (Dx Z00.0X +others)
Available to the patient once (1) per year after the Initial Annual Wellness Visit

  1. [ ] Update patient-generated Health Risk Assessment (HRA)
  2. [ ] Update medical events self/family, hereditary conditions increasing risk. Use of or exposure to meds & supplements.
  3. [ ] Update list of current providers/suppliers that regularly provide medical care
  4. [ ] Measure (Exam): Weight, blood pressure and other exams as needed per history and clinical judgment
  5. [ ] Detect any cognitive impairment: consider health disparities, chronic conditions +other factors that increase risk
  6. [ ] Update written screening schedule for the next 5-10 years based on USPSTF, ACIP, pt’s HRA.
  7. [ ] Update list of risk factors/conditions for which interventions are underway/recommended.
  8. [ ] Furnish, update as necessary, pt’s PPPS aimed at fall prevention, nutrition, nicotine use, etc.
  9. [ ] Furnish, Advance Care Planning (ACP) services at patient’s discretion
  10. [ ] Review current opioid prescriptions (for patients with a current RX): pain evaluated, offer non-opioid options.
  11. [ ] Screen for potential substance use disorders (SUDs): Review risk factors and refer as appropriate.

FQHC’s: The PPS payment rate is adjusted by a factor of 1.3416 when an FQHC furnishes an IPPE or an AWV to a Medicare beneficiary

Advance Care Planning (ACP)

is the face-to-face conversation between a physician (or other qualified health care
professional) and a patient to discuss their health care wishes and medical treatment preferences if they become
unable to communicate or make decisions about their care. At the patient’s discretion, you can provide the ACP
during the AWV. Use these CPT codes to file ACP claims as an optional AWV element:

99497

Advance care planning including the explanation and discussion of advance directives such as standard forms
(with completion of such forms, when performed), by the physician or other QHPl; first 30 minutes, face-to-face with
the patient, family member(s), and/or surrogate

+99498 each additional 30 minutes

Other Medicare Preventive Services

EKG with Preventive Visits

G0403 only w/IPPE EKG screening performed for the IPPE with interpretation and report
G0404 only w/IPPE EKG screening technical component (tracing only)
G0405 only w/Welcome EKG screening (professional interpretation and report only)

Breast and Pelvic

G0101 Medicare breast and pelvic screening exam (annually for high risk, every 24 months for low risk)
Q0091 if PAP today Obtaining PAP smear today

Screening and/or Counseling

G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes
G0444 Annual depression screening, 5 to 15 minutes
G0445 2X/year Counseling to prevent STI/STD 30 minutes

Smoking Cessation

99406 Smoking & tobacco-use cessation counseling; intermediate; >3-10 min
99407 Smoking & tobacco-use cessation counseling; intensive; >10 minutes

Alcohol Misuse

G0442 Annual Alcohol misuse screening 15 minutes
G0443 4 X/year counseling alcohol misuse 15 minutes (If patient screens positive for misuse)

Obesity

G0473 Behavioral counseling obesity; BMI >30; group (2-10); 30 minutes
G0447 Brief Behavioral counseling obesity; BMI >30; 15 minutes
Up to 20 visits per year

See the all inclusive list of preventive services available in the CMS Prevention Quick Reference chart, which includes: HCPCS/CPT/ICD10CM codes, Medicare coverage and frequency for each service. FAQs regarding Medicare prevention visits, patients out of pockets and frequency of services are also identified in the CMS interactive reference chart.

Selected Resources | Check for updates frequently at www.cms.gov

CMS Medicare Prevention Quick Reference Chart
CMS Medicare Wellness Visits (includes details specific to each required element)
CMS Claims Processing Manual FQHCS
CMS Benefits Policy Manual FQHCs
CMS FQHC Guide
CDC Framework for HRA