Insights: Article

Revenue Cycle in a Value-Based World: Preventive Services

By   Deyon Suchla

January 19, 2017

CMS Quality Strategy goals directly align with the many preventive services offered to beneficiaries which are tied to value-based payments. Reimbursement focus continues to be on shifting from the volume of services to the value of services. 

This CMS goal to "Promote effective prevention and treatment of chronic disease" is focused on reduction and prevention of chronic disease as the leading cause of mortality due to lack of medical attention and limited activities of daily living. CMS reports that approximately two out of three Medicare beneficiaries have multiple chronic conditions. For this reason, health care providers are focusing on prevention, screening and education to provide better care that results in reduced spending and healthier beneficiaries.

Revenue Cycle Team is Key
Engaging the revenue cycle team prior to making a change in current services or engaging in providing additional services is key to a successful transition. When providing a new service, much time and energy can be spent on establishing policies and procedures, educating staff and setting up the charge master. However, if the revenue cycle team isn't involved, the claim submission may not appropriately reflect the effort.

  • Coding staff must be involved to ensure compliance with documentation of all the required elements of preventive services.
  • Eligibility verification is crucial to determining the appropriate eligibility dates for frequency restricted services. 
  • Claims processing staff must understand the importance of the place of service or type of bill, revenue codes and HCPCS codes to be reported.
  • Confirm that your clearinghouse is not stripping codes from your claims. Assure that "information only" codes are being received by the carrier for proper reporting.

Key Services
The Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) offer the opportunity to engage with the patient and open the door to the many other preventive services CMS has available to improve or maintain patient's health. Not only are these services offered with no beneficiary deductible or coinsurance responsibility, but come with a higher RVU value incentivizing the provider to perform over the lesser RVU of a typical office visit. Below are the 2016 payment amounts using wage index = 1.00.

  • Level III Office Visit (99213): $73.93
  • Level IV Office Visit (99214): $108.74
  • IPPE (G0402): $168.68
  • Initial  AWV (G0438): $173.70
  • Subsequent AWV (G0439): $117.71

For additional information, Medicare Preventive ServicesThis link takes you to an external website. details the HCPCS and ICD-10 codes used for billing along with coverage and frequency requirements. 

Latest Insights

July 19, 2018
Article
While it’s great to watch your team grow, hiring new employees can be a frustrating and grueling process.
July 19, 2018
Article
Often, human resources (HR) is over looked, but we’re here to tell you it’s an essential component of any organization and critically important to get right.
July 13, 2018
Article
Here are some idea for giving your new hire a smooth start into your business and alleviating stress for you.
July 13, 2018
Article
The impact of the recent SCOTUS Wayfair decision will continue to have a ripple effect on businesses and state sales tax compliance.
July 9, 2018
Article
The revenue cycle is a complex system and we have historically given much attention to the front-end and back-end while oftentimes leaving the middle functions of the cycle neglected.
July 3, 2018
Article
FASB Accounting Standards Codification Topic 606, Revenue from Contracts with Customers, provides a 5-step framework for determining revenue recognition.
July 2, 2018
Article
As part of the Tax Reform Act of 1986, the “Kiddie tax,” a taxing regime designed to make the transfer of income items by wealthy parents to lower tax paying children less attractive, was implemented.
July 2, 2018
Article
When it comes to your employees, you likely conducted interviews on them when you first hired them.
July 2, 2018
Article
Nearly ten years after the release of the initial exposure draft, FASB issued ASU 2016-02, Leases - The standard may have been issued, but the conversation about this re-write of legacy guidance has not slowed.