Samuel “Le” Church, MD, MPH, CPC, CRC

Physician in a rural primary care practice. Active with Georgia Academy of Family Physicians and the American Academy of Family Physicians.

In their attempt to move toward value creation in Medicare, CMS recognizes certain encounters and activities as extremely important to optimizing health and well-being. Therefore, they incentivize PCPs to do the tasks and use codes to be reimbursed for the work. A great example of this is one most of us should know by now: Annual Wellness visits (AWV), G0402, G0438, and G0439.

Dr. Church reminds us that this visit type works as a great springboard to accomplish many things CMS thinks can positively benefit patients. A cognitive screen is required for an AWV. He recommends using that to pivot into an Advanced Care Planning (ACP) discussion (99497). He’ll pose the question during the review of the cognitive screen, “What about if you get dementia? What kind of plans for your healthcare do you have?”

Another doorway to the discussion of ACP can be in patients with chronic medical conditions like heart failure or COPD. Here Dr. Church suggests the pivot of, “What about your heart failure (or other condition)? How does this play into a bigger picture with your health care decisions?” (See BoPC article on Advanced Care Planning)

As we’ve discussed in other BoPC articles, the ACP discussion carries no patient copay when done with the AWV and the -33 modifier is used. However, it adds over $80 to the AWV reimbursement.

Weaving together pertinent discussions and interventions through your everyday clinical work is something all good clinicians do. The good news is there’s probably a code for that to offset some of the extra time you take in being a good clinician. 

Here are three common examples (of many):

1. Obesity counseling (G0447)

2. Smoking Cessation Counseling (99406 or 99407)

3. Cardiovascular Risk Counseling (G0446)

These three risks have a profound impact on patients’ chronic conditions, so if you’re already seeing someone for followup of a chronic condition, bring these conversations into the visit and add them to your 99214 office visit code. 

A great example of this in practice is as follows:

A patient with diabetes and hypertension comes in for a routine check. According to Dr. Church, “You meet the criteria for your level four billing (99214) almost as soon as you go into the room. If the conditions are under control, you can then put your energies into things like cardiovascular disease counseling. After addressing their chronic conditions – even to just say all is going great - shouldn't your conversation really talk about how good control is maintained and how that's reducing your risk for heart attacks and strokes?” If there a high BMI smoker, discuss obesity and smoking cessation, and you can add those codes, as well.

This is one of those CMS-important areas alluded to by Dr. Church, where Medicare is begging docs to have these conversations. CVD risk counseling can be coded as G0446 which yields about $20 reimbursement from CMS. That alone isn’t going to put your kids through college, but it’s work you’re already doing, or should be doing. Code for it! 

Dr. Church framed this well, in my opinion, “You're doing this work already. You just didn't know there was a code for it. It doesn't feel quite as burdensome when you're being compensated for the work that you're doing.” 

He went on to say, “We shouldn't do things just because they’re billable, but we oftentimes don't do things because we don't think it's billable.” Point being sometimes we rush through or skip needed care, thinking we don’t have time, when in reality, we can make the time, because that time will be compensated.

Here’s a cool bit of “office hack” for you: Many of these added codes can be teed up prior to the physician or provider entering the room. The key is to build good processes and automate where you can. 

Dr. Church uses Obesity as an example. “When I walk into the room, the screening has already been started for all the things on our Huddle Sheet, like obesity, smoking, etc. It already has a prompt with their BMI, for example. The preset documentation is just one click away to describe my counseling that I should be bringing into the visit anyway.” (Dr. Church has the appropriate documentation that reflects his conversation pre-loaded and executed with a single click.)

I’ve heard physicians make the argument that there's not time within an office visit to do these things, and they don't get paid enough to do those kinds of things. “I've got to move on,” they think. But what I hear Dr. Church saying is that there is time when you set it up, and you are getting reimbursed for your expertise in how you do primary care.

Leverage technology and workflow to scale out good practice in an affordable way.

Let’s wrap up this list of tips with a practical guide to getting appropriately paid to manage hypertension – a condition with tremendous potential for negative impact on health and outcomes if not controlled.

Dr. Church has developed a process in his office to help manage high blood pressure in patients, starting with educating his front office staff, so they talk about the importance of blood pressure control with patients. When the patient’s vitals are taken, if the blood pressure is up, the team puts a placard on the door indicating an elevated BP. 

The BP gets measured again in a bit. If it’s still up, arrangements are made for a home monitoring device and BP log – all before the doctor sees the patient. They bring it back in and adjustments to treatment are made if needed. Sounds familiar, right?

Here’s the piece some may be missing. 

Many people don't know is there's a code for that. When the patient interacts with the staff and the staff interacts with the physician / provider, and a clinical decision is made and relayed to the patient, with all of it documented in a different note, the code for blood pressure log management – 99474 – can be submitted. 

That code pays about $15. Again, as with CVD Risk counseling, that’s not a huge sum, but it’s work you’re doing, or should do, and this helps cover that time.

Oh, and then you have the patient bring in the BP cuff top the next visit. Your staff can calibrate the cuff to ensure accuracy. That’s code 99473 to be billed in addition to the office visit ($12-13). With this process in place, as Dr. Church puts it, “You’re already doing what’s right. Now it doesn’t feel quite as burdensome when you’re being compensated for the work.”

A big complaint is that there’s not enough money in primary care. Dr. Church would argue that there is, when we know how to properly code for ALL the work that we do to keep our patients healthy. It’s imperative, though, that your practice leverages technology for automation when you setup workflows, so you can build and scale the processes needed to meet this need. This promotes best practice in an affordable, nonburdensome way for the practice, especially when you weave as much of the coding work as possible into the same flow. 

As we’ve said several times already, you’re already doing this work (or should be), so create these processes to get paid for that work.

There are many more of these types of coding tips out there, and BoPC hopes to bring them your way in the future!

About Samuel “Le” Church, MD, MPH, CPC, CRC

Dr. Church is a private practice family physician in Hiawassee, GA, with both office and hospital practices. He is a frequent speaker for medical practices, residency programs, hospital systems, coding conferences, and ACOs in optimized coding and workflow and correct coding. He currently serves on the AMA CPT® Editorial Panel where is also chairs to Immunization Coding Caucus. Dr. Church has a passion for teaching, not only for practicing physicians and coders, but especially medical students and residents. He serves as a core faculty for the Northeast Georgia Medical Center Family Medicine Residency and as adjunct faculty for AU/UGA Medical Partnership SOM. Dr. Church is also serves as the President of the Georgia Academy of Family Physicians. He lives with his wife, Nancy, and their four children on a small farm and frequently partners with her on community projects.

Codes covered in this article:

G0402, G0438, and G0439 – Medicare Annual Wellness Visits

99497 (with -33 modifier) – Advanced Care Planning

G0447 – Obesity Counseling

99406 or 99407 – Smoking Cessation Counseling

G0446 – Cardiovascular Risk Counseling

99474 – Patient collection of BP data reported to a physician or other qualified health care professional and subsequent communication of a treatment plan to the patient

99473 – Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration

Speaking of Codes!!

Here’s a quick reference chart of the big commercial payers and their treatment of the G2211 code for longitudinal management of patients. Of course, Traditional Medicare pays for it, so the MA plans pay as well. Special note: United Healthcare has decided to STOP paying for this code in its non-Medicare population starting 9/1/2024.

In many ways, their model is very similar to mature VBC organizations in how they approach care. There are a couple of differences that caught my eye as innovative, though. One is their use of technology and AI while another is their emphasis on Health Coaching. All of this is tied together with their plan to negotiate with payers for risk. 

Part one of their tech plan is to leverage wearables with their patients to collect biometric data. The assumption is they will provide these for patients unable to afford them, but that is yet to be determined. The biometrics collected are added to demographic and social information gathered on each patient, then put into an AI tool that generates a Digital Twin of the patient. 

Digital twin technology has been most common in manufacturing and mechanical industries where they build a real-time, dynamic, virtual duplicate of a physical object or system – a machine, a part (like a pump), or a process. They then model, simulate, and predict based on recorded wear and performance information gleaned from real-time data from the primary twin (the real one). 

As I was rewatching Apollo 13 last week, I was struck with NASA’s use of digital twinning way back in the late 1960’s as they simulated, projected, and predicted the course and trajectory of the astronauts based on known function and performance of the space module, including adding in the changes they helped the astronauts make. Who knew we’d do the same for people! (Actually, probably a LOT of people have predicted this.)

Digital twins have been used in Cardiology since around 2018, mostly in Electrophysiology for predicting cardiac rhythm issues and in artery blockages to predict success with interventions. Ms. Tuohy and Trueline Health are looking at taking this method mainstream and into primary care. 

Their assumption is that providing this real-time, dynamic, comprehensive, and impactable model to the physicians and providers (it sits on top of the EMR), treatment plans can be suggested, and results projected. Likewise, as this model is shared with a patient, seeing the possibilities and consequences of adhering to a treatment plan (or not), can serve as a great motivator for patients.

Basically, they’re building an LM practice with data support and predictive modeling.

This is where I see a possible obstacle in Trueline quickly getting up to speed. They need to build the best Digital Twin possible, but can they do that without getting additional studies done that are not paid by insurance? This could be a non-issue in their initial Twin build, or it might serve as a negotiation piece after the model shows better outcomes with just conventional testing paid. An intriguing third option would be showing a difference conventional testing versus LM-style diagnostics (paid for by patients or the practice), then leveraging those results with payers.

Either way, if they focus on improved outcomes, they should do well with value-based contracting. It may take some time, but they can work with payers for VBC / outcomes-based contracts, eventually showing the benefit of their practice type and leveraging that for more coverage.

Speaking of outcomes, their care support model also intrigues me. Instead of Nurse Care Managers or Social Workers, Trueline’s frontline person is a Health Coach. While the physician and/or provider guides the medical treatment plan, the Health Coaches are the driving force behind execution of that plan.

Assisted by AI and multimodal communication, the Health Coaches are responsible for building, nurturing, and managing patient relationships, touching base weekly with the folks under their purview.  Of course, the Health Coaches are also assisted by AI tools for engagement and guidance. The concept of frequent touches has been done in other VBC practice models, but they tend to focus on office visits with a physician or provider. The physician still drives the bus in this case, but it’s the Health Coaches that increase the touches with the passengers, increasing the in-office clinicians time and availability.

The application of Lifestyle Medicine principles to primary care can and should improve patient outcomes, both in the short- and long term. I’m encouraged that a practice dedicated to these principles is taking a leap into the VBC pool. Additionally, Trueline’s use of cutting-edge tech and a patient support team based on frequent contact and coaching should prove to be a good shot in the arm for primary care.