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Joseph Scherger

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Coding and definitional issues sabotage ‘wellness visit’ reimbursement


Launched with considerable fanfare, much of Medicare’s seemingly promised payments for “wellness visits” go ¬†unclaimed because of difficult coding and definition issues.

As MedPage Today noted:

“A huge victory in primary care doctors’ quest for better Medicare payment came Jan. 1, 2011, or so they hoped.

“That’s when six pages of the Patient Protection and Affordable Care Act kicked in, authorizing three novel billing codes so that as many as 33 million beneficiaries enrolled in Medicare Part B could receive ‘annual wellness’ visits to help them thwart disease. Nationally, the amounts are significant, paying from $118 to $174 for each code, and possibly more in some locations.”

“But despite this potential largess for primary care, physicians have been slow to submit claims. For the third year of the new codes, only 12% of eligible beneficiaries had Medicare billings for these services, according to 2013 data from the Centers for Medicare and Medicaid Services.

“‘There’s a lot of money and services being left on the table because of the way Medicare has structured this,’ Joseph Scherger, M.D., vice president for primary care at Eisenhower Medical Center, a 48-physician practice in Rancho Mirage, Calif., ¬†told MedPage Today.

“{T}hese visits are different and separate, instead of being integrated into the flow of care. Now, there’s this awkward separatism that offices have to work around. Patients want to talk about their medical problems, but that ends up violating the intent of wellness visit.”







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