How Physicians can Optimize Revenue from Wellness Visits

by | Published on Oct 14, 2016 | Medical Billing

Physicians Optimize
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The Affordable Care Act (ACA) encourages patients to be much more active participants in their own healthcare and learn about their covered medical services. Medicare beneficiaries now get coverage for an Annual Wellness Visit (AWV) – a yearly office visit that focuses on preventive health. Medicare encourages physicians to improve patient care with the AWV and the Initial Preventive Physical Examination (IPPE). However, physicians also need to know how to optimize their revenue from wellness visits. In fact, a recent MedPage report says that a significant amount of Medicare’s wellness visit money goes unclaimed due to physicians’ confusion with medical billing and coding for these services.

The Annual Wellness Visit (AWV) is designed to keep Medicare beneficiaries healthy or to improve their health by promoting positive health habits and a healthy lifestyle. Unlike typical medical care aimed at treating acute and chronic illnesses, the goal of the AWV is preventative, or to slow the advancement and aggravation of existing illnesses. The visits now include not just evaluating symptoms, but also discussions about family history and lifestyle as well as checking the patient’s vital signs, review of medications and charting a schedule for preventative screenings and immunizations.

The three new billing codes that Medicare introduced in 2011 to ensure that family practitioners receive better payment for services provided during annual wellness visits are:

  • G0402 – for a beneficiary’s first “Welcome to Medicare” visit or IPPE if provided within the first 12 months of the beneficiary’s Medicare Part B coverage.
  • G0438 – for a beneficiary’s first visit after they’ve enrolled in Medicare for 12 months if they haven’t had an IPPE previously.
  • GO439 – for the beneficiary’s annual repeat wellness visits.

By billing correctly, physicians can receive as much as $118 to $174 for each code, with the amount being higher in some locations. There is also no 20% co-payment required as in typical Medicare Part B services. According to the MedPage report, all this could amount to billions of dollars in reimbursement for physicians. The dilemma is that most of the money is going unclaimed because of the challenges that physicians face in scheduling and providing AWVs. These include:

  • AWV takes a lot of time, making it difficult for busy physicians to provide
  • Reimbursement provided is considered inadequate for the lengthy visit

Here are some key strategies that can help overcome these issues:

  • Patients need to be educated about the difference between a routine medical exam and a wellness visit. They should know that Medicare does not cover “routine physicals.”
  • If the wellness visit is combined with a regular chronic disease management visit or any other medical discussion, patients can be billed a co-pay for the non-wellness part of the visit.
  • Practices can have a lead nurse manage the AWV, develop the personalized prevention plan (PPP), order relevant screenings or tests, and make necessary referrals. The physician can see the patient briefly at the end.
  • Integrating the AWV with the electronic medical records system will reduce documentation time, ensure an accurate patient health record, and help in developing the PPP. This will also improve family practice medical billing and coding.
  • Relying on professional medical billing and coding services will ensure best practices for claim submission and payment collection.

The AWV offers physicians a great opportunity to increase revenue within their practices, while at the same time enhancing patient care.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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