Betty Lu, PharmD

Medicare Part B provides for its members an annual wellness visit (AWV), given by a Medicare Part B—approved practitioner such as a physician, physician assistant, nurse practitioner, and clinical nurse specialist or a medical professional, such as a pharmacist, who is working under the direct supervision of a physician.

 Patients are eligible if they are members for at least 12 months and have not yet had a visit in the past 12 months.

 There is no co-payment for an eligible Medicare Part B member, and the visit is not subject to a patient’s deductible.

Pharmacists are continuing to expand their role as health care providers with more direct patient care opportunities. Pharmacists working under the supervision of a physician can provide an AWV, which is an exam that focuses on the patient’s health, allowing them the opportunity to develop a personalized approach to health care and disease prevention.

During an AWV, pharmacists should do an overview of the patient’s family, immunization, medical, social, and surgical histories and compile an updated list of current providers. Routine measurements such as blood pressure, height, and weight should be taken. In addition, the pharmacist should perform necessary screenings, including detection of any cognitive impairment, depression, fall risks, and functional ability. A patient’s list of current OTC or prescription medications should be reviewed and documented. Pharmacists can provide patients with a better understanding of their medications, and they are in a unique position to address and resolve any medication issues. Upon reviewing a patient’s overall health, a pharmacist can provide individualized health advice and recommendations. Patients should also be provided with a schedule that reviews the Medicare Part B— covered preventive services that they may require in the next 5 to 10 years, such as immunizations and various screenings. A comprehensive list of these covered screenings can be found on the Medicare website.

An annual physical is different from an AWV, as it consists more of a physical examination that includes the auscultation, inspection, palpation, and percussion of the body. Providers who perform these services are gathering information through their senses to determine whether there is a problem. An annual physical is not a service that falls under an AWV, and it is not covered under the Medicare Part B benefits. The cost for services not covered by Medicare Part B can be billed by a supplemental insurance but is ultimately the patient’s responsibility if it is not covered.

There may seem to be similarities. However, it is important to distinguish between the 2 exams and especially important for the patient to classify the visit as a Medicare AWV so the practitioner can properly bill for the services.

In a physician’s office or a physician-based clinic, a pharmacist may bill services to a physician, using incident-to billing, as long as 9 requirements that Medicare sets forward are met.

 The billing codes used for these services include the Healthcare Common Procedure Coding System code, G0438 for an initial AWV, with a short descriptor of “annual wellness first,” and G0439 for a subsequent AWV, with a short descriptor of “annual wellness subseq.”

The patient must be seen by the physician first for an evaluation or a service covered by Medicare.

An authorization for the service must be provided by the physician in the medical record.

The physician must regularly see the patient at a frequency that is fitting for the management of their course of treatment.

The service provided by the pharmacist is within a physician’s or Medicare Part B provider’s office or clinic.

The service must be medically appropriate to be given in the provider’s office or clinic.

The service provided must be within the pharmacist’s scope of practice.

The services and supplies must be furnished in accordance with applicable state law and adhere to other laws that affect the services.

A physician or a Medicare Part B—approved practitioner must be on the premises when the incident-to services are performed.

The pharmacist must be an employee, contracted or leased, of the physician or Medicare Part B—approved provider.

An AWV with a pharmacist can have a significant impact on patient outcomes. In a 3-month study evaluating 300 patient records, clinical pharmacists completed an average of 5.4 interventions, made 272 referrals, ordered 183 diabetes and lipid screenings, offered 370 vaccinations, and made 24 medication and dosage changes during the AWV.

In supporting the salary of a pharmacist, a study determined that 1070 AWVs a year, which is about 6 visits a day, would be enough to cover this additional cost for a medical practice. This target was more feasible in a larger practice, which would require a lower percentage of total patients. Pharmacists in this setting have the added benefit of providing a patient with a comprehensive medication review while using only about 40% of their time.

Results from a 2013 US Department of Health & Human Services report showed that just 11% of eligible patients across the nation took advantage of their covered AWV.

 In medical practices in which few physicians have the time to reach most of their Medicare Part B—eligible patients, a pharmacist will not only help in this task but also add value through this collaborative effort between the 2 health care professions.

Betty Lu, PharmD, is a graduate of Temple University School of Pharmacy and a fellow of global medical affairs for Massachusetts College of Pharmacy and Health Sciences University/ Becton, Dickinson and Company in Boston.

Jennifer D. Goldman, RPh, PharmD, CDE, BC-ADM, FCCP, is a professor of pharmacy practice at Massachusetts College of Pharmacy and Health Sciences (MCPHS) University in Boston, a faculty preceptor of the MCPHS University/Becton, Dickinson and Company fellowship in medical affairs, and a clinical pharmacist at Well Life in Peabody, Massachusetts.

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. Rev 235, 2017. cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed January 26, 2018.

Physical exam or wellness visit? What Medicare covers. Medicare Made Clear website. blog.medicaremadeclear.com/physical-exam- wellness-visit- what-medicare- covers-2/. Published April 12, 2016. Accessed January 16, 2018.

American Society of Health-System Pharmacists. Pharmacist billing for ambulatory pharmacy patient care services in a physician-based clinic and other non-hospital- based environments- FAQ. ashp.org/-/media/assets/ambulatory- care-practitioner/docs/sacp-pharmacist-billing- for-ambulatory-pharmacy-patient-care-services.pdf. Published May 2014. Accessed January 26, 2018.

Centers for Medicare & Medicaid Services. Annual wellness visit (AWV), including personalized prevention plan services (PPPS). 

. cms.gov/Outreach-and- Education/Medicare-Learning- Network- MLN/MLNMattersArticles/Downloads/MM7079.pdf. Published 2011. Accessed January 26, 2018.

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Articles

Pharmacists are continuing to expand their role as health care providers with more direct patient care opportunities. Pharmacists working under the supervision of a physician can provide an annual wellness visit, which is an exam that focuses on the patient’s health, allowing them the opportunity to develop a personalized approach to health care and disease prevention.
 

Pharmacists and Annual Wellness Visits

Diabetes is a chronic condition characterized by hyperglycemia, because of reduced insulin secretion from the pancreas and/or insulin resistance. Type 1 (T1D) and type 2 (T2D) are 2 main types of diabetes with different presentations and management modalities for improving glycemic outcomes and preventing complications.

T1D is an autoimmune condition where the body destroys beta cells in the pancreas necessary for insulin production. It accounts for 5% to 10% of diabetes cases, and insulin therapy is required. Many patients are diagnosed as children but not all. Most patients have T2D, and though it is usually seen in adults, diagnosis is occurring at younger ages, because of the rise of obesity, a lack of exercise, and poor diets. T2D is associated with insulin resistance and a progressive decrease in insulin production. Metformin is initially the drug of choice for T2D, with other classes being added to reach glycemic goals.

Managing diabetes requires effective patient communication and education for successful treatment plans. Among health care providers, pharmacists are recognized by the American Diabetes Association as an important part of the care management team.

Here is a review on T1D counseling and information essential for pharmacists to know.

Patients with T1D require basal (background) and prandial (bolus) insulin, or basal-bolus therapy. Instead of multiple daily injections, basal-bolus therapy can also be achieved using continuous subcutaneous insulin infusion. Both methods can improve glycemic outcomes in children and adults.

Typically, rapid-acting analogs and basal insulins are preferred over regular human insulin and NPH, because of hypoglycemia, but it is more expensive. Inhaled insulin for prandial coverage is another option, along with biosimilar insulin for basal and prandial insulin, which may offer cost savings for patients.

Insulin is important in T1D. However, if it is used improperly, efficacy and safety can be issues. Key counseling points for patients injecting insulin are proper administration and hypoglycemia treatment. Additionally, pharmacists should be aware of adjunctive therapy for T1D either on or off FDA label.

Proper injection technique is important to improve glycemic control, decrease the risk of hypoglycemia, and reduce lipohypertrophy.

Pen needles lengths are available in 4, 5, 6, 8, and 12.7 mm. Adult skin thickness ranges from 1.25 to 3.25 mm, regardless of age, race, or weight. For most people, longer needles are not needed, and a 4 mm needle would be sufficient to deliver insulin to the right place. Most children have a thinner fat layer than adults, making it important to use the shortest needles. Studies show that 4 mm needles provide equivalent blood glucose control, compared with longer needles, even in obese patients. Patients using shorter needles also reported less pain.

Injection site selection, rotation, and not reusing needles decreases the risk of developing lipohypertrophy (lipo). Lipo occurs when a site is not rotated and may reduce insulin absorption, leading to unpredictable glucose levels. Needles are no longer sterile, become dull, and damaged after 1 use, and this is associated with injection pain or bleeding.

Rotating sites and using new needles every time helps prevent lipo.

Patients injecting insulin are at a higher risk for hypoglycemia, with some common signs including confusion, diaphoresis, dizziness, and shakiness. It is important to recognize these symptoms so that patients can provide proper management.

Patients should be instructed to consume 15 to 20 grams of carbohydrates and check their blood glucose after 15 minutes. If they are still hypoglycemic, repeat the first step. Once the blood glucose is normalized, the patient should eat a small meal or snack. All patients with T1D should be prescribed a glucagon injection, and their families or friends should be educated about how and when to use it.

Pramlintide is FDA approved to add to basal-bolus therapy and is associated with weight loss and lowered insulin doses. It is injected with meals and helps to slow gastric emptying, blunts post-meal glucagon secretion, and increases satiety. Adding metformin could reduce insulin requirements and improve metabolic control. GLP-1 receptor agonists and DPP-4 inhibitors are being evaluated for their potential β-cell mass protection and glucagon release suppression. SGLT-2 inhibitors are used off-label to improve glycemic control and can help with weight loss. Pharmacists should note that the FDA issued a warning of euglycemic ketoacidosis in this drug class, which should be discussed with patients using SGLT-2 inhibitors.

The same counseling on these medications for T2D should be provided in patients with T1D to ensure proper use, improved efficacy, and minimal toxicity.

Diabetes can be managed with the right partnership between the patient and health care team, but sometimes, patients still have difficulty reaching their goals. CGM is a way to capture data on multiple blood glucose levels throughout the day, and it offers a solution by showing glucose fluctuations. Pharmacists can help identify issues or adjust insulin doses based on these trends.

Advancements are continuing to be made for T1D treatments. Pharmacists must stay current with these treatments, as they interact frequently with patients. Education on injection techniques, hypoglycemia, and new options can improve patients’ lives and position pharmacists as an integral part of the care team.

Betty Lu, PharmD is a graduate of Temple University School of Pharmacy and a fellow of global medical affairs for MCPHS University/BD. Jennifer D. Goldman, RPh, PharmD, CDE, BC-ADM, FCCP, is a professor of pharmacy practice at MCPHS University in Boston, Massachusetts, a faculty preceptor of the MCPHS University/BD fellowship in medical affairs, and a clinical pharmacist at Well Life in Peabody, Massachusetts.

American Diabetes Association. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes-2018 [published erratum appears in 

. 2018;41(suppl 1):S73-S85. doi: 10.2337/dc17-S011.

Chiang JL, Kirkman MS, Laffel LMB, Peters AL, Type 1 Diabetes Sourcebook Authors. Type 1 diabetes through the life span: a position statement of the American Diabetes Association. 

. 2014;37(7):2034—2054. doi: 10.2337/dc14-1140.

Frid AH, Kreugel G, Grassi G, et al. New insulin delivery recommendations. 

 2016;91(9):1231-1255. doi: 10.1016/j.mayocp.2016.06.010.

Diabetes is a chronic condition characterized by hyperglycemia, because of reduced insulin secretion from the pancreas and/or insulin resistance.