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The Wellness Exam vs. Well-woman Services under Medicare: Get the Facts

by Heather Cates, ACNM Government Affairs Committee/Midwives-PAC Student Representative

As a student, I spent hours becoming proficient at the art of a thorough, efficient, compassionate well-woman exam. My clinical well-woman site offered me the opportunity to see Medicare patients, and I routinely sat with them and talked about their concerns and performed well-woman screening services when clinically indicated. So, when I heard that CNMs are not reimbursed for wellness exams, I was seriously concerned that I had misunderstood my role with these patients.

The Wellness Exam: A Medicare Phenomenon
Initial and annual wellness exams were created under Medicare and updates were introduced with the 2010 Patient Protection and Affordability Care Act (ACA), effective January 1, 2011. The initial wellness exam includes a “welcome to Medicare” assessment, and then annual “wellness visits” are scheduled. A wellness exam (first visit G0438 or subsequent visit G0439) includes medical and family history, a list of medical providers and medications, height/weight/BMI/blood pressure and other routine measurements, detection of any cognitive impairment, a screening schedule for the next 5-10 years and health advice, and referrals for education and preventive services.

According to Medicare, the wellness exam must be performed by a physician, a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). CNMs/CMs are unable to bill for this service. ACNM will further lobby for CNMs/CMs to be authorized to conduct the wellness exams as health care reform legislation is addressed in the 112th Congress.

Screening Services are Covered
The wellness exams do not include gynecology screening services or any physical exam. However, providers—including CNMs and physicians—are reimbursed for routine gynecology screening services (pelvic, pap, and breast exam). When performed by CNMs and physicians, these preventive services are covered at 100% of the Physician Fee Schedule. Physicians and CNMs are reimbursed at 80%, and the remaining 20% can be billed to the patient. As of right now, CMs do not have billing authorization for these services.

Keep in mind, Medicare will typically only pay for the pelvic, pap, and breast exam screening every two years. If the patient is considered high risk or is of childbearing age and has had an abnormal pap in the preceding 24 months, then the exam is reimbursed every year. If a low-risk woman is seen for an annual exam on the year she is not due for a screening pap, then Medicare does not cover the exam, and the patient will receive the bill. If the patient presents for a problem visit, then bill with the corresponding problem diagnosis and E&M CPT code.

Well-woman Exams or Physicals
If a woman prefers a complete well-woman exam (aka well-woman physical or annual exam), this is not covered by Medicare if performed by CNMs or physicians, but a midwife may initiate this exam. If the woman has supplemental insurance, then the well-woman exam may be partially or completely covered by the supplemental insurance. If done, a well-woman exam is billed with CPT codes 99384-99387 for a new patient, and 99394-99397 for an established patient with modifier -52 for reduced services and an explanation that Medicare is covering a portion of the exam.

We can continue doing preventive well-woman services like we’ve always done for Medicare patients, but Medicare still does not cover comprehensive well-woman exams for CNMs or physicians. Thankfully now, CNMs are reimbursed for gynecologic screening services under Medicare at the same rate as physicians. Any questions?

Please feel free to contact me directly, or check out this very helpful FAQ created by members of the Government Affairs Committee (GAC).

Posted 5/2/2011 2:05:22 PM
 

 

 



Any opinions expressed in this blog are those of the individual participant(s) and do not necessarily reflect the views of the American College of Nurse-Midwives. ACNM is not responsible for accuracy of any of the information provided by guest bloggers and/or members via the Comments section. We welcome all feedback – including comments, ideas and suggestions. We also welcome civil, friendly debates. However, any and all content that is deemed inflammatory or rude will not be posted.

 



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