IPPE beneficiary (Initial Preventive Physical Examination)
The Medicare Prescription Drug Improvement and Modernization Act provides for coverage under Part B of one Initial Preventive Physical Examination (IPPE) for new beneficiaries only (subject to certain eligibility and other limitations, and effective for services furnished). The IPPE may be performed not later than 6 months after the date the individual’s first coverage begins under Medicare Part B.
Medicare will pay for only one IPPE per beneficiary per lifetime, and the Common Working File (CWF) will edit for this benefit. The total IPPE service includes an Electrocardiogram (EKG), but the EKG performed as a component of the IPPE will be billed separately with its own unique Healthcare Common Procedure Coding System (HCPCS) code(s).
The following new HCPCS codes have been developed for the IPPE benefit:
• G0344: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 6 months of Medicare enrollment
• G0366: Electrocardiogram, routine EKG with 12 leads; performed as a component of the initial preventive examination with interpretation and report
• G0367: EKG tracing only, without interpretation and report, performed as a component of the initial preventive examination
• G0368: EKG interpretation and report only, performed as a component of the initial preventive examination
If the EKG performed as a component of the IPPE is not performed by the primary physician or qualified Non-Participating Provider (NPP) during the IPPE visit, another physician or entity may perform and/or interpret the EKG. The referring provider needs to make sure that the performing provider bills the appropriate G code for the screening EKG, and not a CPT code in the 93000 series. Both the IPPE and the EKG should be billed in order for the beneficiary to receive the complete IPPE service. If the same physician or NPP needs to perform an additional medically necessary EKG in the 93000 series on the same day as the IPPE, the provider should report the appropriate EKG CPT code(s) with modifier 59, indicating that the EKG is a distinct procedural service.
The instructions for billing the IPPE, failed to take into account an existing hospital Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) edit.
The OPPS OCE (Version 6.0) like all previous OPPS OCEs, contains an edit that 1) requires a modifier 25 on any Evaluation and Management (E/M) HCPCS code if 2) there is also a status “S” or “T” HCPCS procedure code on the claim.
The HCPCS code for the IPPE (or Welcome to Medicare Physical) uses an E/M code, G0344, and the HCPCS code for the technical component only of the EKG, G0367, has a status indicator of S.
Therefore, this instruction directs hospital outpatient departments (subject to the hospital OPPS) that want to obtain payment for the IPPE (G0344) to do the following:
• Append modifier 25 to the HCPCS code for the IPPE itself (HCPCS code G0344) when the technical component of the EKG (G0367) is billed on the same claim.
Also, Fiscal Intermediaries (FIs) are to process any provider requests for adjustments if the FI initially denied the claim for HCPCS code G0344.