Initial Preventive Physical Examination

The following HCPCPS codes are used to report these services:

G0402 – Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during first six months of Medicare enrollment

G0403 – Electrocardiogram, routine ECG with at least 12 leads: with interpretation and report, performed as a component of the initial preventive physical examination

G0404 – Tracing only, without interpretation and report, performed as a component of the initial preventive physical examination

G0405 – Interpretation and report only, performed as a component of the initial preventive physical examination

This examination (referred to as the IPPE or “Welcome to Medicare Exam”) covers specific services for new Medicare beneficiaries. The exam is payable once and only if provided within the first twelve months of the beneficiary’s first Part B coverage period. The usual deductible is waived, but co-insurance provisions apply.

The service may be provided by a physician or qualified non-physician provider (e.g., physician assistants (PA), nurse practitioners (NP), and clinical nurse specialists (CNS).

The IPPE includes the following:

• Medical and social history: Review of patient’s history with particular attention to modifiable risk factors for disease.

• Depression Risk Assessment: Review of the patient’s risk factors for depression, including current or past experience with depression or other mood disorders. She cannot have a current diagnosis of depression. The provider may use one of the standardized screening tests designed for this purpose and recognized by national medical professional organizations.

• Functional ability and level of safety: Review based on the use of appropriate screening questions or a screening questionnaire. The provider may select from screening questions or standardized questionnaires designed for this purpose and recognized by national medical professional organizations.

• Examination: Measurements and tests including measurement of the patient’s height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate, based on her medical and social history and current clinical standards.

• Effective January 1, 2009, the examination element of the IPPE now requires measurement of body mass index to identify those at risk for weight-related health problems.

•  Optional Electrocardiogram: Performance and interpretation by provider or by referral provider.

•  Education, counseling, and referral: Provided as appropriate, based on the results of the first five elements of the IPPE.

•  End of Life Planning (Upon an individual’s consent): End-of-life planning is defined as verbal or written information regarding: (1) an individual’s ability to prepare an advance directive (AD) in the case that an injury or illness causes the individual to be unable to make health care decisions, and (2) whether or not the physician is willing to follow the individual’s wishes as expressed in the AD.

•  Brief written plan such as a checklist: Provided to the patient for obtaining appropriate screening and other preventive services which are separately covered under Medicare Part B benefits (e.g., screening services described above, vaccinations, diabetes self-management, glaucoma screening, medical nutrition therapy)

For the purposes of the IPPE benefit, medical history is defined as:

• Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatment.

• Current medications and supplements, including calcium and vitamins.

• Family history, including a review of medical events in the patient’s family, including diseases that may be hereditary or place the individual at risk.

For the purposes of this benefit, social history is defined as:

• History of alcohol, tobacco, and illicit drug use.

• Diet.

• Physical activities.

If the physician or NPP cannot perform the EKG in the office suite, then alternative arrangements may be made with an outside entity. The primary care provider must incorporate the results of the EKG into the beneficiary’s medical record.

The diagnosis code reported is V70.0 (routine general medical examination at a health care facility).
Other covered preventive, screening or problem-oriented services may be performed at the same encounter as the IPPE. These are reported using the appropriate codes. If reporting an E/M service, add a modifier 25. The documentation for the problem-oriented portion of the encounter must support the level of service reported.

Billing and Coding Guidelines

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse the Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed. When a Preventive Medicine service and Other E/M services are provided during the same visit, only the Preventive Medicine service will be reimbursed.

Screening services include cervical cancer screening; pelvic and breast examination; prostate cancer screening/digital rectal examination; and obtaining, preparing and conveyance of a Papanicolaou smear to the laboratory. These Screening procedures are included in (and are not separately reimbursed from) the Preventive Medicine service rendered on the same day.

Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes. Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes. Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes. Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services

Are clinical laboratory tests part of the IPPE?

No. The IPPE does not include any clinical laboratory tests, but you may make referrals for such tests as part of the IPPE, if appropriate.

Do deductible or coinsurance/copayment apply for the IPPE?

No. Medicare waives both the coinsurance/copayment and the Medicare Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening ECG (HCPCS codes G0403, G0404, or G0405).

If a beneficiary enrolls in Medicare in 2016, can he or she have the IPPE in 2017 if it was not performed in 2016?

A beneficiary who has not yet had an IPPE and whose initial enrollment in Medicare Part B began in 2016 is eligible for an IPPE in 2017 as long as it is done within 12 months of the beneficiary’s first Medicare Part B enrollment effective date.

Annual Wellness Visit Coding Tips

• G0438 is for the first AWV only and is paid only once in a patient’s lifetime.

• G0438 and G0439 must be not be billed within 12 months of a previous billing of a G0402, G0438 or G0439 for the same patient. Such subsequent claims will be denied.

• If a claim for a G0438 or G0439 is billed within the first 12 months after the effective date of the patient’s Medicare Part B coverage, it will also be denied. A patient is eligible for only the “Welcome to Medicare” physical in the first 12 months of eligibility  When a provider performs a separately identifiable medically necessary E/M service in addition to the AWV with PPPS, CPT codes 99201-99215 reported with modifier -25 may also be billed. When medically indicated, this additional E/M service would be subject to the applicable deductible, copayment or coinsurance for office visits.