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Hint: It’s Your AWV Workflow
The claims data supporting the power of Medicare’s Annual Wellness Visits (AWV) is eye-opening. The average annual cost benchmark for a Medicare beneficiary is $10,000. If a patient gets an AWV, that cost burden to taxpayers is reduced by 5.7%. There are few programs under the Value-Based Care umbrella that perform better. Yet, only 19% of all Medicare patients get an AWV? Why are we so bad at ensuring patients get an AWV?
There are three reasons providers fail to complete Medicare Annual Wellness Visits (AWV):
- Providers are resistant because they believe AWVs take up too much time
- Providers have not been educated on the benefits of AWVs or capture options
- Providers confuse Physicals for AWVs
Let’s Talk Time
If the provider is spending significant time with a patient during an AWV, ordering labs and tests to be completed that day, they are missing the point of this visit. The yearly completion of the Health Risk Assessment (HRA) by the patient is meant to initiate a meaningful conversation between the provider and the patient about the next steps. Recommending a follow-up visit to tackle some of the tertiary services should only take a few minutes. In fact, neither the provider nor the patient needs to be in the exam room until the HRA is completed. With that in mind, the most efficient workflow is to have the patient complete the HRA in the waiting room and then append the AWV CPT code to any E&M visit. Just as important, the AWV technology used to create the provider report from an HRA should include logic that parses and highlights patient issues that need attention and doesn’t force the provider to read through pages and pages of an HRA. AWV’s can and should be efficient and not burden the daily workflow of a practice.
Need more time? CMS says an AWV can be completed by an RN or LPN under the direct supervision of the billing provider. That means that the provider need not even be in the room as long as the clinician and the provider are in the same building on the bill date. This is particularly helpful for our FQHC and RHC clients. In all cases, the nurse must be licensed in the same state as the patient’s billing provider.
Benefits of AWVs
Does your ACO nag you about AWV capture rates? The reason ACOs encourage providers to complete AWVs is because of the valuable 5-10 year care plan generated from the HRA portion of the AWV. The patient’s answers in the HRA are filled with information identifying risks and alerting you to the gap closures and quality measures that need to be addressed and reported. Opportunities to talk to your patients about everything from mammograms, flu vaccines, patient education opportunities, and Advanced Care Planning (ACP) are identified from the patient’s answers to the HRA.
You might be asking yourself, ‘Wait, are you suggesting we tack the AWV onto any E & M visit?’ Yes, that is exactly what should be done. CMS knows how valuable this visit is to the patient, the practice and even CMS itself, and they have removed barriers in order to increase AWV capture rates in a way that minimizes the interruption to the provider’s schedule, improves care of patients, and helps practices maximize reimbursements. No-show rates for preventative care encounters, like AWVs, often exceed 40%. The key to success is to turn a sick visit into a well visit. Simply have a patient complete the HRA in the waiting room while they are waiting for their already scheduled sick visit with the provider.
Standard, non-FQHC or RHC practices, can capture AWVs during an E & M visit, via telehealth during the pandemic, or even as a stand-alone AWV visit with all three options providing the same outcome and identical reimbursement. The best practice workflow is to hand the patient the HRA while they are in the waiting room, with simple instructions on completing their questionnaire. The provider will then see the patient for the E & M sick encounter visit as scheduled, briefly discussing next steps based on the HRA’s outcome at the end of the visit. Your billing gurus will then add a 25 modifier to the E & M visit along with the correct AWV G-code (G0438 or G0439) to receive full reimbursement for the E & M visit as well as the $165 – $135 reimbursement respectively for the completed AWV.
Similarly, Federally Qualified Health Centers (FQHCs) can add an AWV to an E & M visit. Not only will you learn valuable information about your unique patient, CMS will then give FQHCs their national average based on the Prospective Payment System (PPS) and a financial bump of about 34% resulting in an extra $60 reimbursement when an AWV is completed. FQHCs will bill for the E & M visit, adding two additional codes, G0468 and the appropriate AWV G-code (G0438 or G0439), along with a PS modifier for each G-code to alert CMS that they are Preventative Services and should not carry a copay.
Unfortunately, guidelines for Rural Health Clinics (RHCs) are a little more complicated. AWVs cannot be added to an E & M visit for any reimbursement of the AWV. CMS only allows RHCs to receive reimbursements for AWVs if they are completed as a stand-alone visit or a telehealth visit. The best practice for an RHC is to have the patient complete the HRA during a sick or visit, and then have the patient set up a follow-up visit to complete the AWV on a separate day. This would allow the RHC to bill the AWV as a standalone visit for their full All-Inclusive Rate (AIR). Insider tip: During the pandemic, CMS is allowing RHCs a bit of flexibility with telehealth services that were not previously available. If a patient no-shows their follow-up, AWV-only visit, a nurse, under the direct supervision of the provider, can call the patient to complete the AWV over the phone, record recent vitals, and then bill CPT code G2025, with a 95 modifier to receive a reimbursement of $99.45.
AWV vs Physical
First, AWVs and Physicals are two separate visit types. While we can all appreciate the thorough, thoughtful provider who wants to spend 45 minutes to an hour with each Medicare patient completing a full physical examination, lab work, and renewing prescriptions, this visit does not have the same clinical value as an AWV and results in a hefty price tag for the patient. Not only will Medicare not cover a yearly physical exam, but any tertiary services provided during a physical will also incur a 20% cost-sharing balance for the patient. AWVs on the other hand, are completely free to the patient.
Unlike a physical, an AWV is a “Visit to develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA),” per CMS (CMS AWV MLN, Feb 2021).
The HRA is a self-guided questionnaire completed by the patient or their caregiver that provides insight into how the patient perceives their health. The answers selected by the patient during the HRA are aggregated into a 5-10 year care plan for the patient, and a 5-10 year list of preventive services, tests, and educational opportunities for the provider to address during subsequent visits. An AWV is meant to be as simple as it sounds, and when done correctly, it is free to the patient and incredibly beneficial to both patients and providers.
In sum, Annual Wellness Visits need not take up valuable provider time in order for the patient and the provider to see the benefits. Patients learn ways to proactively manage their own health, providers learn more about each of their unique patients maximizing reimbursements while doing so, and the detailed, logic-driven, prevention plans derived from HRAs help practices and ACOs to fill gaps in care to achieve quality measures. Sadly, you are missing out on this very achievable opportunity for your patients, providers, and practice by not taking advantage of the many creative workflows encouraged by CMS allowing you to capture these informative Annual Wellness Visits. If you have questions or would like some guidance on best practices, compliant workflows for AWVs, please don’t hesitate to reach out to us to start a conversation with an expert.