OFFICE MANAGER: I mean, look at these claims.
Denied, approved, denied, denied, approved. I can’t make sense of it.
Why would Medicare cover some of these physicals and not others? It seems random.
PHYSICIAN: I doubt they’re just rolling the dice.
Maybe we’re getting denials for errors we’re not catching.
Let’s tackle the first claim and figure out where we went wrong.
OFFICE MANAGER: I wish someone could guide us down the right path,
usher along our quest for answers.
PHYSICIAN: Let’s call the MAC!
Dial tone.
Numbers being dialed.
Phone ringing.
MAC: Medicare Administrative Contractor. How may I assist you?
OFFICE MANAGER: Hi, so Medicare denied our claim for this office visit…
What kind of visit?
An Initial Preventive Physical Exam?
An Annual Wellness Visit?
Or a Routine Physical Checkup?
OFFICE MANAGER: Aren’t those the same thing?
PHYSICIAN: Not exactly.
They’re like apples and oranges and... mangoes.
MAC: Medicare does not cover Routine Physical Checkups,
but it does cover Initial Preventive Physical Exams and Annual Wellness Visits.
An Initial Preventive Physical Exam is a one-time
“Welcome to Medicare” visit given to newly-enrolled beneficiaries.
An Annual Wellness Visit can happen once a year.
It’s where you perform a health risk assessment
and develop or update a beneficiary’s personalized prevention plan.
If a visit’s not one of these two
and it does not treat or diagnose something specific,
it’s probably just a Routine Physical Checkup.
What’s more,
Initial Preventive Physical Exams and Annual Wellness Visits are covered by Medicare,
whereas Routine Physicals are not.
Keep in mind that if you provide services that are not an aspect of an Annual Wellness Visit,
the beneficiary may owe a copay or other charges.
Communication is key.
When you talk to your patients,
make sure they know which services are covered by Medicare.
It’s important to clarify that they might be responsible for some or all of the costs for services that are not covered.
PHYSICIAN: Alright, let’s take a look at Ms. Jennings’ visit.
It’s coded as a Routine Physical.
But maybe it was something else?
Let’s see.
Ms. Jennings asked for an Annual Wellness Visit,
so first I checked her eligibility
by asking if it’s been more than 12 months since her Medicare Part B kicked in
and if she’s received an Initial Preventive Physical Exam or Annual Wellness Visit in the last year.
I determined that this is the patient’s first Annual Wellness Visit.
Since this was her first Annual Wellness Visit,
she completed her health risk assessment before she came in, so I went over it with her.
Then, I established her medical and family history,
and we made a list of her current providers.
We reviewed her medications, including her current opioid prescriptions and supplements.
MAC: Those are definitely components of an Initial Annual Wellness Visit.
The health risk assessment can be administered independently by the patient
or by a health professional prior to or as part of the Annual Wellness Visit.
PHYSICIAN: Then, I took some routine measurements, like her height, weight and blood pressure,
all while observing whether she had any cognitive impairment.
MAC: These are part of an Initial Annual Wellness Visit, too.
PHYSICIAN: Based on this information, I established a screening schedule
and made a list of risk factors that might require further attention.
MAC: Check and check.
PHYSICIAN: Finally, I answered her questions and referred her to resources that she might find helpful.
MAC: There you have it.
Sounds like you hit all the components of an Initial Annual Wellness Visit.
If this had been a Subsequent Annual Wellness Visit you would update all of these elements.
PHYSICIAN: It’s easy to mix them up in the moment. I’ll be more careful when I fill out charts.
OFFICE MANAGER: And I’ll double check the codes before I file the claims.
MAC: For future reference,
you can find all the codes you need in the Medicare Claims Processing Manual.
OFFICE MANAGER: So, just to make sure,
how was Ms. Jennings’ visit different from a Routine Physical?
MAC: The Annual Wellness Visit is a chance to gather information on a patient’s history and risk factors
so you can help them plan how to prevent future illnesses
and provide some educational resources.
Keep in mind that the requirements differ for Initial and Subsequent Annual Wellness Visits.
If it’s not an Initial Preventive Physical Exam or an Annual Wellness Visit
and does not treat or diagnose something specific,
it’s probably a Routine Physical Checkup,
which isn’t covered by Medicare.
PHYSICIAN: Well, now that we know that Ms. Jennings’ visit was an Annual Wellness Visit,
we can resubmit the claim with the correct code.
OFFICE MANAGER: Done! Thank you!
MAC: Sounds like you have everything you need! I think my work here is done.