The Medicare Wellness Exam
MARC PRICE, DO
FAMILY MEDICINE OF MALTA, PHYSICIAN
OWNER
NYSAFP TREASURER AND ADVOCACY CHAIR
Overview
 The History behind the Medicare Wellness
Exams
 What are the Medicare Wellness Exams
 What is covered by the Medicare Wellness
Exams
 How to code for the Medicare Wellness
Exams
The History
 3/23/10 - The Patient Protection and
Affordable Care Act
 Amended 3/30/10 – Health Care And
Education Reconciliation Act
 Goal
 To
end some of the worst abuses by the insurance
industry and to award Americans new rights and
benefits
 4 Year roll implementation
The Medicare Wellness Exams
 In the words of CMS:
“CMS is committed to promoting the appropriate use of
Medicare preventive services. Medicare now covers a
broad range of services to prevent disease, detect disease
early when it is most treatable and curable, and manage
disease so that complications can be avoided…”
 “…CMS recognizes the crucial role that health care
providers play in providing and educating Medicare
beneficiaries about potentially life-saving preventive and
services and screenings.”

What is Covered
 Preventive services

Initial Preventive Physical Exam (IPPE)
 AKA

Welcome to Medicare Preventive Physical
Annual Wellness Visit (AWV)
 Screenings
 Vaccinations
 Behavior therapy and counseling
Welcome to Medicare (IPPE)
 Once in a lifetime

Within 12 months of initiation of Medicare Part B coverage
 Copay/Coinsurance:

No
 Elements

History
Medical and social history
 Screening for depression/mood disorders
 Functional ability and safety evaluation


Examination


Assessment for end-of-life planning
Counseling and Education

Including a written plan
Annual Wellness Visit (AWV)
 Initial visit vs Subsequent visit

Not within 12 months of starting benefits or last IPPE/AWV
 Copay/Coinsurance:

No
 Elements

History


Same as IPPE
Examination
Same as IPPE, but no mention of end-of-life planning
 List of current healthcare providers and suppliers


Counseling and Education
Written screening schedules, interventions and health advice
 Referrals to health education or preventive counseling services

IPPE and AWV Clarifications
 “Preventive wellness visits” are not annual
physical exams
 Can be performed by a qualified health
professional
 Although specific labs/tests are not included
in the IPPE or AWV, tests may be ordered
resulting from the exam
 One-time AAA screening only covered if
ordered during an IPPE, not an AWV
IPPE and AWV Clarifications
 A diagnosis code is required, but not a
specific one
 Confirm an IPPE or AWV hasn’t been
performed within the past 12 months
 Separate E/M and medically necessary
services can be billed at the same time as the
IPPE or AWV with modifier -25
Screening
 EKG


IPPE only
Copay/Coinsurance: Yes
 Ultrasound for AAA


IPPE only and if meets certain criteria
Copay/Coinsurance: No
 Cardiovascular Screening - Lipids


Every 5 years
Copay/Coinsurance: No
Screening
 Diabetes – fasting/non-fasting glucose/GTT



Non-diabetics meeting criteria
1-2 times per year depending on previous results
Copay/Coinsurance: No
 Glaucoma


Annually if criteria met
Copay/Coinsurance: Yes
 Bone Mass Measurement


Every 2 years if criteria met (sooner if medically necessary)
Copay/Coinsurance: No
Screening
 Colorectal Cancer – several options


Age > 50 yo, timing varies depending on test and risk factors
Copay/Coinsurance: No
 Prostate – DRE/PSA


Annually beginning the day after 50th birthday
Copay/Coinsurance: PSA – No/ DRE – Yes
 Depression


Annually
Copay/Coinsurance: No
Screening
 Pap Tests


Annually if certain criteria met, otherwise every 2 years
Copay/Coinsurance: No
 Pelvic Exams


Annually if certain criteria met, otherwise every 2 years
Copay/Coinsurance: No
 Mammography


Female 35-39 yo - one baseline, >40 yo – annually
Copay/Coinsurance: No
Screening
 Alcohol Misuse


Annual screening
Copay/Coinsurance: No
 Sexually Transmitted Infections

Women – GC/Chlamydia/Syphilis/Hepatitis B


Men – Syphilis only


Annually for increased risk, 1-3 times per pregnancy (dz dependant)
Annually for increased risk
Copay/Coinsurance: No
 HIV


Annually for high risk patients, 3 times per pregnancy
Copay/Coinsurance: No
Vaccinations
 Seasonal Influenza


Once per season, more if medically necessary
Copay/Coinsurance: No
 Pneumonia


Once in a lifetime, more if medically necessary and > 5 yrs
since last
Copay/Coinsurance: No
 Hepatitis B


Scheduled dosing if at high or intermediate risk
Copay/Coinsurance: No
Vaccinations
 Those NOT covered under Medicare Part B


Zoster Vaccine
TDaP

Though covered under Medicare Part D (medications)
Counseling
 Diabetes Self-Management Training


Individual or group; 10 hrs 1st year, 2 hrs subsequent years
Copay/Coinsurance: Yes
 Medical Nutrition Therapy

Individual or group; 3 hrs 1st year, 2 hrs subsequent years


Diabetes, renal disease/kidney transplant within 3 yrs
Copay/Coinsurance: No
 Intensive Behavioral Therapy for CV Disease


Individual; Annually
Copay/Coinsurance: No
Counseling
 Intensive Behavioral Therapy for Obesity


Individual; Multiple visits over 6-12 months
Copay/Coinsurance: No
 Tobacco Use


Two cessation attempts per year; up to 4 sessions per attempt
Copay/Coinsurance: No
 Alcohol Misuse (Not Dependence)


Individual; Four visits per year
Copay/Coinsurance: No
 Sexually Transmitted Infection Prevention


Individual; Twice per year
Copay/Coinsurance: No
How To Code
How To Code
How To Code
How To Code
How To Code
How To Code
How To Code
Resources
 http://www.cms.gov/Medicare/Prevention/Prevntio
nGenInfo
 http://www.cms.gov/Medicare/Prevention/Prevntio
nGenInfo/Downloads/MPS_QuickReferenceChart_1
.pdf
 http://www.medicare.gov/coverage/preventive-andscreening-services.html
 http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/PreventiveServices.html
Questions?
 Contact Information

Marc Price, D.O.
2388 Route 9, Suite 200, Mechanicville, N.Y. 12118
 518-899-5390
 drprice@nycap.rr.com
 Twitter: Bald_and_Proud
