Annual Wellness Visit (AWV) and Advanced Care Planning ...



Annual Wellness Visit (AWV) and Advanced Care Planning (ACP) WorkflowTaskResponsible Party (WHO)Action (WHAT)Date (WHEN)Notes/CommentsCodesIdentifyMedical OfficeMedicare covers an AWV providing a Personalized Prevention Plan Services for Patients who are:no longer within 12 months after the effective date of their first Medicare Part B Coverage PeriodHave not received an Initial Preventive Physical Exam or AWV within the past 12 monthsConsiderations-How do you identify the population?Options-Search for population of Medicare eligible for Initial and Annual Wellness Visit-Search for population of Medicare eligible who are due for Initial and Annual Wellness Visit by query of last 6 months of billing codesMonthly-6The AWV is not a routinePopulationAssistant, ClericalSupport Staffmonths beforethe due date forPhysician Checkup Medicare doesnot cover routine physical examsBilling Codeseach patient or atlast AWVNo labs are to be included as part of the AWVBoth coinsurance/copayment and deductible are waived.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.Pre-visit planningMedical Office Assistant, Clerical Support StaffPrepare patient education on outstanding health maintenance services1-3 days prior to AWVGenerate the health maintenance reports prior to the exami.e. Run the report on whether or not they are due for preventive health servicesSchedule PatientMedical Office Assistant, Clerical Support StaffHealth Risk Assessment must be completed for the AWVThis can be sent via the patient portal or completed when the patient arrives for appointment.As identified during the task of population identified as schedule allowsWorkflow decisions:The AWV is done as a completely separate visit or it is done with an MD office visit.Patient arrives and is checked inMedical Office Assistant, Clerical Support StaffTaskResponsible Party (WHO)Action (WHAT)Date (WHEN)Notes/CommentsCodesAWV BeginsMD, DO, PA, NP orHRA should include:Demographic DataSelf-assessment of health statusPsychosocial RiskBehavioral riskActivities of Daily Living(ADL’s), including but not limited to dressing, bathing and walkingInstrumental ADL’s including but limited to shopping, housekeeping, managing own medications and handling financesScreening for depression (PHQ-2/9) as well identification for inclusion in chronic care management can be completed at the time of the HRAAt AWVICD 10 CodesCCNS, or MedicalProfessional(Including-HeathEducator, RegisteredZ00.0 Encounter for general adult medical examinationZ00.00 …… without abnormal findingsHRAAdministered/Updateddietitian,nutritional professional or other licensed practitioner OR a team of medicalprofessionals whoZ00.01 …… with abnormal findingsare directlysupervised by aphysician)Use current staff and enable themto practice at thehighest level oftheir scope ofpractice/job dutiesThis person will bereferred to as theAWV CoordinatorEstablish/AWV CoordinatorInclude current clinicians andAt AWVObtain and update contactReview list ofsuppliers (DME, Home Health,informationcurrentproviders andMeals on Wheels) that regularlyprovide medical care/services tosuppliersthe beneficiaryEstablish / Review patient Medical/Family HistoryAWV CoordinatorFamily Medical HistoryPast Medical and Surgical HistoryMedication review including nonprescription medicationsAt AWVMIPS Quality Measure (QM)130- Documentation of Current Medications in the Medical RecordCPT II Codes1159F Medication list documented in medical record (COA)1160F Review of all medications by a prescribing practitioner or clinical pharmacist (such as, prescriptions, OTCs, herbal therapies andsupplements) documented in the medical record(COA)TaskResponsible Party (WHO)Action (WHAT)Date (WHEN)Notes/CommentsCodesDepression or other mood disorder screeningAWV CoordinatorPHQ 2 or PHQ 9, AUDITAt AWVAnnuallyMIPS QM 134- Preventive Care and Screening: Screening for Depression and Follow-Up PlanMIPS QM 371- Depression Utilization of the PHQ-9Billing Codes:G0444-Annual Depression Screening(Included in AWV)HCPCS1220F (patient screened for depression)3725F (screening for depression performed) Pick one:G8510-Screening for depression is documented as negative, a follow-up plan is not requiredG8428-Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not givenG8511-Screening for depression documented as positive, follow-up plan not documented, reason not givenG8940-Screening for clinical depression documented as positive, a follow-up plan not documented, documentation stating the patient is not eligibleG9393-Patient with an initial PHQ-9 score greater than nine who achieves remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than fiveG9395-Patient with an initial PHQ-9 score greater than nine who did not achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score greater than or equal to fiveG9509-Adult patients 18 years of age or older with major depression or dysthymia who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5G9573-Adult patients 18 years of age or older with major depression or dysthymia who did not reach remission at six months as demonstrated by a six month (+/-60 days) PHQ-9 or PHQ-9M score of less than fiveGO442- Annual Alcohol Misuse screening. (Add on for a separate visit, except for some MA plans)HCPCSTaskResponsible Party (WHO)Action (WHAT)Date (WHEN)Notes/CommentsCodesG0442 Annual alcohol misuse screening, 15MIPSQM 431- AlcoholminutesMIPS QM 226- Tobacco ScreeningG0443 Brief face-to-face behavioral counseling foralcohol misuse, 15 minutesCPTII CodesTobacco Use1034F Current tobacco smoker1035F Current smokeless tobacco user1036F Current tobacco non-user3016F Patient screened for unhealthy alcoholuse using a systematic screening method (PV)(DSP)4000F Tobacco use cessation intervention,counseling4001F Tobacco use cessation intervention,pharmacologic therapy4320F Patient counseled regarding psychosocialand pharmacologic treatment options for alcoholdependence (SUD)ReviewAWV CoordinatorTools- Direct observation and fallAt AWVMIPS QM 154- Fall RiskCPTII Codespatientsfunctional ability and level of safetyrisk assessment (Consider Homesetting)AssessmentMIPS QM 155- Falls: Plan of CareMIPS QM 182- Functional Outcome AssessmentMIPS QM 318- Falls: Screening for Future Fall Risk1100F Patient screened for future fall risk; documentation of two or more falls in the past year or any fall with injury in the past year1101F Patient screened for future fall risk; documentation of no falls in the past year or only one fall without injury in the past year3288F Falls risk assessment documentedCapture BMI,AWV CoordinatorAssess and Document in MedicalAt AWVMIPS QM 128- BMI with F/UCPTII CodesHT, WT, BPincludes other routine measure- mentsRecordMIPS QM 317- B/P Screening and Follow up3008F Body Mass Index (BMI) documented3074F Most recent systolic blood pressure < 130 mm Hg3075F Most recent systolic blood pressure 130-139 mm Hg3077F Most recent systolic blood pressure > 140mm Hg3078F Most recent diastolic blood pressure < 80mm Hg3079F Most recent diastolic blood pressure 80-89mm Hg3080F Most recent diastolic blood pressure >90TaskResponsible Party (WHO)Action (WHAT)Date (WHEN)Notes/CommentsCodesObserve forAWV CoordinatorTools- Direct Observation, familyAt AWVMIPS QM 281- Dementia:Cognitivemember/caretaker feedback or aCognitive Assessmentimpairmentstandardized like the Mini CogMIPS QM 282- Dementia: Functional Status AssessmentMIPS QM 286- Dementia: SafetyConcern Screening and Follow-Upfor Patients with DementiaMIPS QM 288- Dementia:Education and Support ofCaregivers for Patients withDementiaTaskResponsible Party (WHO)Action (WHAT)Date (WHEN)Notes/CommentsCodesEstablish a written screening schedule for the patient and update EHR with due dates for next 5-10 years.AWV CoordinatorIdentify age/gender appropriate screening.United State Preventive Services task ForceAdvisory Committee on Immunization PracticesMedicare Preventive ServicesAt AWVMIPS QM 439-Age Appropriate Screening ColonoscopyMIPS QM 185- Colonoscopy Interval for Patients with a History of Adenomatous Polyps– Avoidance of Inappropriate UseMIPS QM 320-Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk PatientsMIPS QM 112- Breast Ca ScreeningMIPS QM 309- Cervical Cs ScreeningMIPS QM 110- Preventive Care and Screening: Influenza ImmunizationMIPS QM 111- Pneumonia Vaccination Status for Older AdultsMIPS QM 113- Colorectal Cancer ScreeningMIPS QM 225- Radiology: Reminder System for Screening MammogramsMIPS QM 474- Zoster (Shingles) VaccinationMIPS QM 475- HIV ScreeningCPTII Codes3014F Screening mammography results documented and reviewed3017F Colorectal cancer screening results documented and reviewed3015F Cervical cancer screening results documented and reviewed1030F Influenza immunization status assessed4274F Influenza immunization administered or previously received4037F Influenza immunization ordered or administered1022F Pneumococcus immunization status assessed4040F Pneumococcal vaccine administered or previously receiveTaskResponsible Party (WHO)Action (WHAT)Date (WHEN)Notes/CommentsCodesScheduleAWV CoordinatorEvaluate enrollment in ChronicAt AWVIf a non-provider is performing the AWV, all ICD 10 codes used must have been previously documented by the MD, NP or PA.(Alert MD if new ICD 10 codes are identified during the AWV)If performed with another E/M service, use the 25 modifierAll current Diagnosis should be include. This willneededCare Management Programimpact your cost score of MIPS.referrals/immunizations/self- managementTobacco-use cessation counseling, Obesity counseling, Diabetes Self- management Trainingand wellnessresources andnext AWV aswell asdocumentappropriateICD 10 codesfor the patientAdvancedAWV CoordinatorFace to Face conversationMIPS QM 47- Advance Care PlanCPT Billing Codes99497-Advanced care planning including the explanation and discussion of advance directives- first 30 minutes99498-Advanced care planning including the explanation and discussion of advance directives- each additional 30 minutesCPTII Codes1157F Advance care plan or similar legal document present in the medical record 1158F Advance care planning discussion documented in the medical record1123F Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical recordCare Planningbetween a qualified heath care(Optionalbut highlyrecommend- ed)professional and a beneficiary todiscuss the patient’s wishes andpreference for medical treatment if he or she were unable to speak-Bill with modifier 33 and may be billed at the same time as the AWVor make decision in the future.-Deductible/coinsurance for ACPis waived once per year whenbilled with the AWV.-An advanced directive formdoes not have to be a product ofthe conversation.-30 minute code-min. thresholdis 16 minutesPatient checks outMedical Office AssistanceClerical AssistanceReferences? Annual Wellness Visit? CMS Advance Care Planning Guide? Medicare Preventive Services Tool? Medicare Preventive Services National Educational Products? Medicare Preventive Services? Preventive visit & Yearly Wellness Exams? The ABC’s of the Annual Wellness Visit? 2019 Clinical Quality Measure Specifications & Supporting Documents986877158190This material was prepared by Alliant Health Solutions, for Alliant Quality, the Medicare Quality Innovation Network – Quality Improvement Organization for Georgia and North Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 11SOW-AHSQIN-D1-18-36 ................
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