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Monetizing Wellness

In 2011 the Centers for Medicare and Medicaid Services (CMS) started paving the way for clinicians to promote beneficiaries’ wellness when it implemented the initial preventive physical exam (HCPC G0402). Until that point most Medicare beneficiaries saw providers only for illness issues. Providers couldn’t bill for wellness visits.

It has taken several years for both providers and patients to adjust to the fact that providers can see Medicare patients for wellness, not sickness. Even today there are many Medicare patients who only see their provider if ill, never thinking about the care they can utilize to stay well and out of the hospital. Likewise, there are many providers who don’t think about scheduling wellness visits for their geriatric patients.

Wellness Codes and Reimbursement

Let’s look at what wellness billing codes are now available and their reimbursement rates.

Evaluation and Management (CPT 99201–992015/99211–99215)—These traditional CPT codes for illness visits are reimbursed by CMS (Medicare Administrative Contractor) approximately $41–$197.

Initial Preventive Physical Exam (HCPCS G0402)—This service is reimbursed approximately $159 but is only allowed once in the lifetime for the beneficiary (age 65).

Annual Wellness Visit (HCPC G0438) and Subsequent Annual Wellness Visit (HCPC G0439)—These are reimbursed approximately $110–$164, with the Subsequent Wellness Visit allowed to be billed annually.

Transition Care and Chronic Care

In 2013 CMS laid another brick in the road and instituted the Transition Care Management Service codes (CPT 99494 and 99496) in an attempt to better facilitate the care of recently discharged patients and reduce the frequency of readmissions.

These CPT codes also reimburse the provider for their service and time in reconciling medications, arranging social services, ordering physical therapy and providing other services intended to prevent the patient from being readmitted. The Transition Care Management Service codes pay approximately $156–$219, more than the traditional CPT E/M codes in the areas of revenue that were used previously for similar services by providers.

In 2015 CMS agreed to pay providers for assisting patients who have multiple chronic care conditions (CPT 99490) in an attempt to address the many complex issues these patients have and try to keep them from being admitted.

Reimbursement of the Chronic Care Management Service code pays approximately $41 for a minimum of 20 minutes a month with some preplanning. Although this amount is not as much as the Wellness Visits or the Transition Care Management Services, if planned accordingly during the Wellness Visit or a sick visit (using the traditional CPT E/M codes), this code can be used monthly in order to manage the patient’s multiple chronic care conditions.

How else has CMS tried to address chronic care issues and wellness in the past? Medicare Part C (Advantage Insurance Plans) started tracking chronic medical conditions many years ago. Many of these insurance carriers also offer beneficiaries wellness clinics. The insurance carriers and CMS started seeing the correlation between identifying chronic care conditions and the benefits of various wellness programs such as diabetic clinics. CMS started to put a numeric weight on various chronic care diagnosis codes. These categories of chronic care codes are called Hierarchical Condition Categories (HCC). The sum of the weights is called the Risk Adjustment Factor (RAF).

The goal of CMS with the HCC/RAF system is to track chronic care conditions so that the Medicare Advantage (Part C) programs are allotted the correct amount of money for taking care of this segment of CMS beneficiaries. Many times the Part C plan offers wellness programs that address issues such as diabetes. Providers are often given stipends from the Medicare Advantage programs for correct and timely documentation of chronic care conditions. Providing good care and correct documentation along with accurate medical coding of patients with chronic diagnoses makes a lot of financial sense for everyone involved.

For example, take these diagnoses:

  • Diabetes with ophthalmic manifestations, Type II (ICD-10 code E11.39)—weight 0.37;
  • Chronic kidney disease, Stage IV (ICD-10 code N18.6)—weight 0.22;
  • Unstable angina (ICD-10 code I20.0)—weight 0.26;
  • Prostate cancer (ICD-10 code C61)—weight 0.15.

These diagnoses have a combined weight (RAF score) of 1.4, which also includes a weight for the geographic area where the beneficiary lives—in this case 0.43. Anything over a 1 is considered good medical coding for providers who see a lot of chronic care patients.

Documentation of all of the chronic conditions must be found in the patient’s medical chart note, dated and signed appropriately by the correct provider. Providers who see patients insured by Medicare Part C should be documenting all chronic care conditions every year, starting each January 1.

Maintaining Coding Compliance

All CPT codes and HCPC codes have rules on how to use them, when to use them, frequency of use, appropriate modifiers that should be appended, etc. Make sure to consult your compliance professional regarding these guidelines and rules. The compliance professional wears the ruby red slippers and should always be able to guide you down that twisty path! Remember that the Affordable Care Act requires that all providers have a compliance plan and compliance point of contact.

This journey of coding events that CMS has led providers and beneficiaries on is a yellow brick road to wellness. However, providers need to remember what codes are available to use and remind patients to come in for the services that are available to them.

Everyone wins with wellness. We just need to have a path to follow to a healthier mind, body and pocketbook. Consider sitting down with your staff to start the planning stage of when to schedule patients for their wellness visits. Try to get all patients in as early in the year as possible in order to meet all deadlines. Discuss all chronic care issues during this visit. Make sure the patient knows they are to have someone contact your office if they are admitted to the hospital. Use your electronic medical record/electronic health record to assist you, thus also meeting various Meaningful Use criteria. Communication with staff, patients and our EMR/EHR is the key! 

Jacqueline Nash Bloink, MBA, RHIA, CHC, CPC-I, CPC, CMRS, is professor of health information technology at Saddleback College in Orange County, Calif.; medical coding and billing instructor for Ultimate Medical Academy in Florida; and compliance consultant at Jacqueline Bloink LLC in California. Contact her at 

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