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.
• 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 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
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.