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Revenue Cycle in a Value-Based World: Preventive Services

By   Rhonda Quast, 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.