MARCH 29, 2018
Betty Lu, PharmD, and Jennifer D. Goldman, RPh, PharmD, CDE, BC-ADM, FCCP
Medicare Part B provides for its members an annual wellness visit (AWV), given by a Medicare Part B–approved practitioner such as a physician, physician assistant, nurse practitioner, and clinical nurse specialist or a medical professional, such as a pharmacist, who is working under the direct supervision of a physician.1 Patients are eligible if they are members for at least 12 months and have not yet had a visit in the past 12 months.2 There is no co-payment for an eligible Medicare Part B member, and the visit is not subject to a patient’s deductible.2
Pharmacists are continuing to expand their role as health care providers with more direct patient care opportunities. Pharmacists working under the supervision of a physician can provide an AWV, which is an exam that focuses on the patient’s health, allowing them the opportunity to develop a personalized approach to health care and disease prevention.
During an AWV, pharmacists should do an overview of the patient’s family, immunization, medical, social, and surgical histories and compile an updated list of current providers. Routine measurements such as blood pressure, height, and weight should be taken. In addition, the pharmacist should perform necessary screenings, including detection of any cognitive impairment, depression, fall risks, and functional ability. A patient’s list of current OTC or prescription medications should be reviewed and documented. Pharmacists can provide patients with a better understanding of their medications, and they are in a unique position to address and resolve any medication issues. Upon reviewing a patient’s overall health, a pharmacist can provide individualized health advice and recommendations. Patients should also be provided with a schedule that reviews the Medicare Part B– covered preventive services that they may require in the next 5 to 10 years, such as immunizations and various screenings. A comprehensive list of these covered screenings can be found on the Medicare website.2
An annual physical is different from an AWV, as it consists more of a physical examination that includes the auscultation, inspection, palpation, and percussion of the body. Providers who perform these services are gathering information through their senses to determine whether there is a problem. An annual physical is not a service that falls under an AWV, and it is not covered under the Medicare Part B benefits. The cost for services not covered by Medicare Part B can be billed by a supplemental insurance but is ultimately the patient’s responsibility if it is not covered.2
There may seem to be similarities. However, it is important to distinguish between the 2 exams and especially important for the patient to classify the visit as a Medicare AWV so the practitioner can properly bill for the services.
In a physician’s office or a physician-based clinic, a pharmacist may bill services to a physician, using incident-to billing, as long as 9 requirements that Medicare sets forward are met.3 The billing codes used for these services include the Healthcare Common Procedure Coding System code, G0438 for an initial AWV, with a short descriptor of “annual wellness first,” and G0439 for a subsequent AWV, with a short descriptor of “annual wellness subseq.”4
The 9 requirements are:
The patient must be seen by the physician first for an evaluation or a service covered by Medicare.
An authorization for the service must be provided by the physician in the medical record.
The physician must regularly see the patient at a frequency that is fitting for the management of their course of treatment.
The service provided by the pharmacist is within a physician’s or Medicare Part B provider’s office or clinic.
The service must be medically appropriate to be given in the provider’s office or clinic.
The service provided must be within the pharmacist’s scope of practice.
The services and supplies must be furnished in accordance with applicable state law and adhere to other laws that affect the services.
A physician or a Medicare Part B–approved practitioner must be on the premises when the incident-to services are performed.
The pharmacist must be an employee, contracted or leased, of the physician or Medicare Part B–approved provider.
An AWV with a pharmacist can have a significant impact on patient outcomes. In a 3-month study evaluating 300 patient records, clinical pharmacists completed an average of 5.4 interventions, made 272 referrals, ordered 183 diabetes and lipid screenings, offered 370 vaccinations, and made 24 medication and dosage changes during the AWV.5
In supporting the salary of a pharmacist, a study determined that 1070 AWVs a year, which is about 6 visits a day, would be enough to cover this additional cost for a medical practice. This target was more feasible in a larger practice, which would require a lower percentage of total patients. Pharmacists in this setting have the added benefit of providing a patient with a comprehensive medication review while using only about 40% of their time.6
Results from a 2013 US Department of Health & Human Services report showed that just 11% of eligible patients across the nation took advantage of their covered AWV.6 In medical practices in which few physicians have the time to reach most of their Medicare Part B–eligible patients, a pharmacist will not only help in this task but also add value through this collaborative effort between the 2 health care professions.
Betty Lu, PharmD, is a graduate of Temple University School of Pharmacy and a fellow of global medical affairs for Massachusetts College of Pharmacy and Health Sciences University/ Becton, Dickinson and Company in Boston.
Jennifer D. Goldman, RPh, PharmD, CDE, BC-ADM, FCCP, is a professor of pharmacy practice at Massachusetts College of Pharmacy and Health Sciences (MCPHS) University in Boston, a faculty preceptor of the MCPHS University/Becton, Dickinson and Company fellowship in medical affairs, and a clinical pharmacist at Well Life in Peabody, Massachusetts.
Centers for Medicare & Medicaid Services. Covered medical and other health services. In: Medicare Benefit Policy Manual. Rev 235, 2017. cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed January 26, 2018.
Physical exam or wellness visit? What Medicare covers. Medicare Made Clear website. blog.medicaremadeclear.com/physical-exam- wellness-visit- what-medicare- covers-2/. Published April 12, 2016. Accessed January 16, 2018.
American Society of Health-System Pharmacists. Pharmacist billing for ambulatory pharmacy patient care services in a physician-based clinic and other non-hospital- based environments- FAQ. ashp.org/-/media/assets/ambulatory- care-practitioner/docs/sacp-pharmacist-billing- for-ambulatory-pharmacy-patient-care-services.pdf. Published May 2014. Accessed January 26, 2018.
Centers for Medicare & Medicaid Services. Annual wellness visit (AWV), including personalized prevention plan services (PPPS). MLN Matters. cms.gov/Outreach-and- Education/Medicare-Learning- Network- MLN/MLNMattersArticles/Downloads/MM7079.pdf. Published 2011. Accessed January 26, 2018.
Alhossan A, Kennedy A, Leal S. Outcomes of annual wellness visits provided by pharmacists in an accountable care organization associated with a federally qualified health center. Am J Health Syst Pharm. 2016:73(4):225-228. doi: 10.2146/ajhp150343.
Park I, Sutherland SE, Ray L, Wilson CB. Financial implications of pharmacist-led Medicare annual wellness visits. J Am Pharm Assoc (2003). 2014:54(4):435-440. doi: 10.1331/JAPhA.2014.13234.
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