Posts Tagged CDC
By Jacqueline Nash Bloink, MBA, CPC-I, CHC
The Centers for Medicare & Medicaid Services (CMS) has begun a campaign to educate Medicare beneficiaries about preventive services, including wellness visits, available to them. There is even a YouTube clip to promote these visits. If CMS believes these visits are such a great service for the beneficiary, why do so many physicians cringe when they hear an appointment has been scheduled for such a service?
Manage Patient Expectations
Beneficiaries often expect a head to toe examination during the wellness visit, but this is not what it delivers. Office staff must begin to educate the beneficiary that the wellness visit is a plan of care. When the beneficiary understands the wellness visit was created to take a snap shot of his or her current health status, and the physician won’t be performing a physical examination, the situation will be better controlled—meaning fewer angry beneficiaries and more physicians willing to perform the service.
Staff should also inform beneficiaries they will not incur a co-pay for a wellness visit, but if another service is provided during the visit, there will be a co-pay for that portion of the visit.
CMS has many educational resources available to physician offices to assist with explaining wellness visits to patients, including a downloadable patient brochure.
Three Visit Types, Three Sets of Requirements
There are three types of wellness visits, each of which has different requirements.
1. G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment describes the “welcome to Medicare preventive visit.” The beneficiary can only receive this visit during the first year that he or she is eligible and enrolled in Medicare. If the patient does not exercise his or her right to request this visit during that first year, he or she will never again have the chance to request it.
During this visit, the beneficiary is eligible for a screening electrocardiograph (EKG) (G0403-G0405) and aortic aneurism ultrasound (AAU), if he or she meets the following requirements:
- Patients may be eligible for the screening EKG if a referral is given during the welcome to Medicare preventive visit (G0402).
- AAU is provided as a one-time screening if the beneficiary gets a referral as a result of the welcome to Medicare preventive visit (G0402). Eligible patients are those who either have a family history of abdominal aortic aneurysm or if the patient is male, aged 65-75, who has smoked at least 100 cigarettes during his lifetime, and the patient has never had an AAU paid for by Medicare during his or her lifetime.
For more detail on the EKG and AAU screenings, visit the CMS website: www.medicare.gov/navigation/manage-your-health/preventive-services/preventive-service-overview.aspx).
2. After 11 full months have passed, the beneficiary is eligible for the next wellness visit. G0438 Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit describes the “initial Medicare wellness visit.” This visit can be performed at any point in the beneficiary’s life, but only once during his or her lifetime. This code was implemented by CMS in 2011.
3. After 11 full months have passed since the initial wellness visit, the beneficiary is eligible for the “subsequent” wellness visit (G0439 Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit). A beneficiary can request this visit every year (after 11 full months have passed between visits), if so desired.
You can find a summary of the requirements of all Medicare wellness visits on the CMS website.
Create a Template to Make Documentation Easy
If the physician’s office combined all of the components of each of the three visits together to create one master template, as shown in Example A, the beneficiary would get a few extra benefits each year, while making things easier for the physician.
Items in red represent the services the physician provided during the visit that may have not been needed during that particular visit, but were required in one of the other visits. If all 10 steps are performed during the G0402, G0439, or G0438 visit, the provider does need to stop and think which component he or she is missing, making life much easier for both physician and patient.
By following a template for documenting wellness visits, the staff becomes familiar with the steps, and patients become accustomed to the questions and are prepared to answer them each year.
The health care team at the office (medical assistant, licensed practical nurse, or registered nurse) may be able to assist the health care professional (nurse practitioner or physician assistant) in obtaining 75 percent of the information prior to the physician entering the room to talk with the patient. Each year, the physician will have a written description of the beneficiary’s lifestyle and will be better prepared to address various risks that the patient may face as he or she ages.
With the wellness visit well-documented, all that remains is scheduling next year’s wellness visit (remember: at least 11 full months after this visit).
10 Easy Steps to Document Medicare Wellness Visits
1. Patient completes the required “Health Risk Assessment Questionnaire” prior to the visit with the physician (this is new for 2012). Guidelines for creating a form with all of the necessary components can be found at the Centers for Disease Control and Prevention (CDC) website.
2. Office staff documents the patient’s height, weight, blood pressure, body mass index (BMI), and visual acuity.
3. Patient’s medical history, family history, and social history are discussed and documented. Special attention is paid to past illnesses, surgeries, allergies, and injuries. Family history is pertinent with hopes of catching high-risk areas that may be modifiable or identified with special screening tools. The social history will be helpful in documentation of substance abuse such as smoking or alcohol.
4. Patient is queried about current or past events of depression. Make sure to list the type of depression tool used to determine the risk. Examples of such tools might include PQ1, PQ2, or Zing.
5. List all current medications, including vitamin supplements.
6. List all current providers and suppliers that the patient is seeing (specialists, diabetic suppliers, etc.).
7. Assessment of functional ability and safety: This must include:
- Daily living activities
- Risk of falling
- Safety/home life/risks
8. Cognitive impairment assessment and observation. Information may also be obtained from the patient’s family, caregivers, or friends.
9. End-of-life planning and advance directives. Does the physician agree with this plan?
10. Written plan of preventive services that the patient is eligible for the next one to 10 years. The patient takes this plan when he or she leaves the office.
Jacqueline Nash Bloink, MBA, CPC-I, CHC, lives in Tucson, Ariz. and is director of compliance for Arizona Community Physicians.
August 1st, 2012
The Centers for Disease Control and Prevention (CDC) held a Morbidity and Mortality Weekly Report (MMWR) telebriefing July 19 on pertussis, or whooping cough, and the epidemic that’s occurring in Washington state. According to Dr. Anne Schuchat, director for the National Center for Immunization and Respiratory Diseases at CDC, Washington state is not alone in its plight. “What is happening in Washington state is a reflection of the larger national picture. … We’re seeing a substantial increase in pertussis cases in the United States and in individual states like Washington,” Schuchat said.
Washington state has had 2,520 cases of pertussis this year as of June 16, but the number of cases reported nationwide is even more concerning. “As of today, nationwide, nearly 18,000 cases have been reported to CDC,” Schuchat said. “That’s more than twice as many as we had at the same time last year. In fact, it’s more than we had in each of the past five years. We may be on track for record high pertussis rates this year. We may need to go back to 1959 to find a year with as many cases reported by this time so far. So, there is a lot of pertussis out there and I think there may be more coming to a place near you.”
Pertussis is most dangerous for babies and very young children. Early symptoms can include runny nose, low-grade fever, and mild, occasional cough—similar to that of a cold. Infants may experience apnea (a pause in breathing). As the disease progresses, the coughing becomes more persistent and might create a “whooping” sound. Relentless coughing fits that can come and go for weeks on end cause exhaustion, which compromises immunity.
Young children aren’t the only ones at risk, however. Schuchat said, “We’re also seeing high rates … among children 10 years of age. By age 10, immunity can wane from the early-childhood vaccines that kids get.” The CDC is also seeing an increase nationally in the 13-to-14 year age group. “The increased number of cases among 13-to-14 year olds is a concern we are looking at in detail,” Schuchat said.
Pertussis vaccine remains the single most effective approach to prevent infection. The CDC continues to recommend that all children and adults get fully vaccinated to prevent infection and to protect infants.
Adolescents 11-18 years of age (preferably at age 11-12 years) and adults 19 through 64 years of age, as well as adults 65 and older who have close contact with an infant and have not previously been vaccinated, should receive a single dose of Tdap. Tdap should also be given to 7-10 year olds who are not fully immunized against pertussis. Children should get five doses of DTaP, one dose at each of the following ages: 2, 4, 6, and 15-18 months, and 4-6 years.
Pertussis is generally treated with antibiotics and early treatment is very important. The CDC is asking clinicians who see patients with a persistent cough or who may have been exposed to the disease to consider pertussis as a diagnosis (ICD-9-CM 033.9 Whooping cough, unspecified organism).
“Be proactive with treatment, especially with pregnant women, infants, and others who are around infants,” urged Schuchat.
July 26th, 2012
Diabetes patients have seen a decline in death rates due to better medical management and treatment, according to the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH). A study published by the American Diabetes Association in the journal Diabetes Care, “Trends in Death Rates Among U.S. Adults With and Without Diabetes Between 1997 and 2006,” shows that between 1997 and 2006:
- Deaths related to heart disease and stroke fell by 40 percent for diabetics.
- Deaths from all causes among diabetics decreased by 23 percent.
National Health Interview Survey data of almost 250,000 adults was analyzed by researchers and showed, according to ModernPhysician.com, “People with diabetes were less likely to smoke and were more physically active than before, and there was also better management of high blood pressure and high cholesterol.” Unfortunately, weight management was not a factor in the study; obesity rates continue to rise among people with diabetes, researchers say.
June 1st, 2012
Weed through the guidance to properly append this commonly confused modifier.
By G.J. Verhovshek, MA, CPC, and Rita Von Holtum, CPC-H
Nearly 18 months since its introduction at the American Medical Association’s (AMA’s) 2010 CPT® Symposium, modifier 33 Preventive service continues to cause confusion. Here, we review eight quick tips that teach you when and how to append modifier 33.
1. Know Where to Find Information
The AMA published guidance for applying modifier 33 in the December 2010 CPT® Assistant, and followed up with brief entries in CPT® 2012 Changes: An Insider’s View and “Appendix A —Modifiers” of the CPT® 2012 manual. Private payers have also begun to issue guidance on modifier 33 (Search the Web to see if your payer does.).
As CPT® Assistant explains, modifier 33 was created in response to the Patient Protection and Affordable Care Act (PPACA), which requires all health care insurers to cover certain preventive services and immunizations without cost sharing. In other words, insurers must waive the co-pay and deductible and pay, in full, for specified covered services. By appending modifier 33, the provider alerts the insurer that a covered preventive service was provided, and that patient cost sharing does not apply.
2. Know Which Services Are Covered
Only select preventive services and immunizations are fully covered under PPACA. You may append modifier 33 to identify preventive services that fall into the following four categories, per AMA instructions:
1. Services rated “A” or “B” by the U.S. Preventive Services Task Force (USPSTF). Services with an “A” rating have been judged to have a high certainty that the net benefit is substantial. Services with a “B” rating have been judged to have a high certainty of moderate to substantial net benefit. A listing of these services is updated and posted annually on the Agency for Healthcare Research and Quality’s website.
2. Preventive care and screenings for children as recommended by Bright Futures (American Academy of Pediatrics) and Newborn Testing (American College of Medical Genetics), as supported by the Health Resources and Services Administration (HRSA).
3. Preventive care and screenings provided for women (not included in the USPSTF recommendations) in the comprehensive guidelines supported by HRSA. Examples falling into the categories above include HIV screening in adults and adolescents at an increased risk for HIV infection, bacteriuria screening for pregnant women, blood pressure screening in adults, and colorectal cancer screening in adults beginning at age 50.
4. Immunizations for routine use in children, adolescents, and adults as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Examples include Zostavax immunization in adults; inactivated polivirus for children; and hepatitis A and B, human papillomavirus, measles, mumps, and rubella, and influenza for both adults and children.
Nearly five dozen preventive screening and immunization services are covered under PPACA, and may be reported with modifier 33. When reporting a claim with modifier 33, medical records are not required, but must be available upon request.
3. Apply Modifier 33 for Private Payers Only
The Centers for Medicare & Medicaid Services (CMS) has not issued any guidance for modifier 33. There’s a good reason for this: Medicare and Medicaid do not recognize modifier 33.
Claims submitted to Medicare containing modifier 33 will be returned with Medicare Outpatient Adjudication (MOA) code MA130, which indicates that the claim contains incomplete and/or invalid information that is “unprocessable.” As such, you should only append modifier 33 for non-Medicare payers, as per AMA instructions.
Medicare is not exempt from the requirements of PPACA, and must pay in full for covered services; however, Medicare requires the use of dedicated G codes that specifically describe covered services as preventive (e.g., G0202 Screening mammography, producing direct digital image, bilateral, all views). A guide to Medicare-covered preventive services may be found on the Medicare website.
4. Turn to 33 for Screening Turned Diagnostic
You may also apply modifier 33 when a preventive service must be converted to a therapeutic service. “The most notable example of this,” according to CPT® Assistant, “is screening colonoscopy [45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)] that results in a polypectomy [e.g., 45383 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique].”
Reminder: Apply modifier 33 only for commercial carriers. Medicare does not accept modifier 33. If a screening colonoscopy leads to polyp removal for a Medicare patient, report the appropriate removal code (e.g., 45383) with modifier PT Colorectal cancer screening test; converted to diagnostic test or other procedure—rather than modifier 33—appended.
5. Selected Services Covered In-network Only
Insurers are permitted to require cost sharing for those services that are not covered under PPACA. Insurers also are permitted to impose cost sharing—or choose not to provide coverage—for recommended preventive services provided out-of-network. Treatment resulting from a preventive screening is subject to cost-sharing if it is not a recommended preventive service.
6. Apply 33 to All Eligible Services
If a physician provides multiple preventive medical services to the same (non-Medicare) patient on the same day, append modifier 33 to the codes describing each preventive service rendered on that day.
7. Cost Sharing Doesn’t Apply for Separate, Same-day Services
The insurer may not impose cost sharing if the primary reason for an office visit is to receive a preventive service; however, per the AMA, cost-sharing is allowed for an office visit if the office visit and covered preventive service are billed separately, and the primary purpose of the office visit is not to deliver the covered preventive service. To illustrate, CPT® Assistant provides the following examples:
- “A 45-year-old male individual receives a cholesterol screening test, which is a recommended preventive service, during an office visit for hypertension management. The plan or issuer may impose cost-sharing requirements for the office visit because the recommended preventive service is billed as a separate charge and the office visit was not primarily for preventive services.”
- “An individual receives a recommended preventive service that is not billed as a separate charge. The primary purpose for the office visit is a recurring abdominal pain and not the delivery of a recommended preventive service. Therefore, the plan or issuer may impose cost-sharing requirements for the office visit.”
- “An individual receives a recommended preventive service that is not billed as a separate charge, ie, it is part of the office visit and the delivery of said service is the primary purpose of the office visit. Therefore, the plan or issuer may not impose cost-sharing requirements for the office visit.”
8. Designated Preventive Services Don’t Require 33
Do not append modifier 33 for “separately reported services specifically identified as preventive,” per CPT® Appendix A. Included in this category are any HCPCS Level II G codes for preventive services, such as G0202 (screening mammography), G0103 Prostate cancer screening; prostate specific antigen test (PSA), and G0389 Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening. Use HCPCS Level II codes to describe services provided for Medicare and Medicaid beneficiaries. Use CPT® codes, when applicable, to report services for patients covered by private insurance.
For example, to report a covered screening mammography for a non-Medicare patient, you would report 77057 Screening mammography, bilateral (2-view film study of each breast). Modifier 33 is not required because 77057 is a designated screening service. To report the same service for a Medicare patient, report G0202. Modifier 33 is neither required nor accepted by Medicare.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.
Rita Von Holtum, CPC-H, lead coder at Sanford Health, has been working in health care for 33 years. Working for a smaller facility, she has worn many hats including coding ED, outpatient, ambulatory surgery, and inpatient accounts. In 2001, she became a certified coder with AAPC. Rita is on the facility Compliance Committee, where her departments work with the Corporate Compliance department on changes and concerns. She mentors new and fellow coders.
May 1st, 2012
If you see an increase in HIV screening in your pediatrician/family practice office, it’s because new American Academy of Pediatrics (AAP) guidance encourages pediatricians to know the symptoms of early-stage HIV and openly discuss sexual activity and other sexually transmitted diseases (STDs) with patients.
An estimated 1.2 million people 13 and older were living with HIV in the United States at the end of 2008, the Centers for Disease Control and Prevention (CDC) said. Of those infected, 5.8 percent were adolescents and young adults between the ages of 13 to 24. With more than half unaware they have the disease, this age group were the least likely to know they were infected, according to CDC data.
To help reduce infections in this age group, the AAP recommends pediatricians to test routinely their adolescent patients for HIV. In communities where more than 0.1 percent is infected with the virus, physicians should offer all patients between the ages of 16 and 18 the test at least once, the AAP says.
The AAP encourages physicians to regularly screen patients for sexual activity and substance use, so no cases are overlooked. Pediatricians should recognize the symptoms of the early stages of HIV infection, which include influenza-like illness, diarrhea, mononucleosis symptoms, fever, and skin rash.
Source: Moyer, Christine S.; “HIV Testing Recommended for Teens and Young adults,” amednews.com, Nov. 14, 2011.
December 1st, 2011
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