Initial Preventive Physical Examination (IPPE)
Also known as the “Welcome to Medicare Preventive Visit”.
HCPCS/CPT Codes
G0402 – IPPE
G0403 – EKG for IPPE
G0404 – EKG tracing for IPPE
G0405 – EKG interpret & report for IPPE
Who Is Covered
All new Medicare beneficiaries who are within the first 12 months of their first Medicare Part B coverage period
Frequency
Once in a lifetime
Must furnish no later than 12 months after the effective date of the first Medicare Part B coverage period
Medicare Beneficiary Pays G0402:
* Copayment/coinsurance waived
* Deductible waived
G0403, G0404, and G0405:
* Copayment/coinsurance applies
* Deductible applies
Notes on Medicare Part B Preventive Services
a For dates of service on or after January 1, 2011, the Affordable Care Act allows for coverage of an Annual Wellness Visit (AWV), providing Personalized Prevention Plan Services (PPPS). For more information, refer to “The ABCs of Providing the Annual Wellness Visit” (ICN 905706) at http://www.cms.gov/MLNProducts/downloads/AWV_QRI_ICN905706.pdf on the Centers for Medicare & Medicaid Services (CMS) website.
b Effective for dates of service on or after August 25, 2010, Medicare provides coverage of counseling to prevent tobacco use.
c A Medicare beneficiary with certain risk factors for AAAs may receive a referral for a one-time preventive ultrasound screening for the early detection of AAAs. Important: Eligible beneficiaries must receive a referral for an ultrasound screening for AAA as a result of an IPPE.
Use the following Healthcare Common Procedure Coding System (HCPCS) codes, listed in the table below, when filing claims for the IPPE.
IPPE HCPCS CODES BILLING CODE DESCRIPTORS
G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
G0403 Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretationand report
G0404 Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination
G0405 Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventivephysical examination
Frequently Asked Questions • • •
Is the IPPE the same as a beneficiary’s yearly physical?
No, this exam is a preventive physical exam and not a “routine physical checkup” that some seniors may receive every year or two from their physician or other qualified non-physician practitioner. For a newly enrolled beneficiary, the IPPE is an introduction to Medicare and covered benefits. Medicare does not provide coverage for routine physical exams.
Who can perform the IPPE?
The IPPE must be furnished by either a physician (a doctor of medicine or osteopathy) or a qualified non-physician practitioner (a physician assistant, nurse practitioner, or clinical nurse specialist).
Are clinical laboratory tests part of the IPPE?
No, the IPPE does not include any clinical laboratory tests, but the provider may want to make referrals for such tests as part of the IPPE.
Is there a deductible or coinsurance/copayment for the IPPE?
Coverage for the IPPE is provided as a Medicare Part B benefit. For dates of service prior to January 1, 2011, the annual Medicare Part B deductible is waived for the IPPE (HCPCS code G0402), but the coinsurance or copayment still applies. The deductible still applies to the optional screening
EKG (HCPCS codes G0403, G0404, or G0405). For dates of service on or after January 1, 2011, both the Medicare Part B deductible and the coinsurance or copayment are waived for the IPPE only. Neither is waived for the screening EKG.
If a beneficiary enrolled in Medicare in 2010, can he or she have the IPPE in 2011 if it was not performed in 2010?
A beneficiary, who has not yet had an IPPE and whose initial enrollment in Medicare Part B began in 2010, will be able to have an IPPE in 2011, as long as it is done within 12 months of the beneficiary’s initial Medicare Part B enrollment effective date.
Can a separate Evaluation and Management (E/M) service be billed at the same visit as the IPPE?
Medicare payment can be made for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201-99215) billed at the same visit as the IPPE when billed with modifier-25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.
Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)
A.Definitions
1.Initial Preventive Physical Examination (IPPE)
The initial preventive physical examination (IPPE), or “Welcome to Medicare Preventive Visit” is a preventive visit authorized by sections 1861(s)(2)(w) and 1861(ww) of the Social Security Act (and implementing regulations at 42 CFR 410.16, 411.15(a)(1), and 411.15(k)(11)).
As described in the implementing regulations, the IPPE includes the following:
(1)review of the individual’s medical and social history with attention to modifiable risk factors for disease detection,
(2)review of the individual’s potential (risk factors) for depression or other mood disorders,
(3)review of the individual’s functional ability and level of safety,
(4)an examination to include measurement of the individual’s height, weight, body mass index, blood pressure, a visual acuity screen, and other factors as deemed appropriate, based on the beneficiary’s medical and social history,
(5)end-of-life planning, upon agreement of the individual,
(6)education, counseling, and referral, as deemed appropriate, based on the results of the review and evaluation services described in the previous 5 elements, and
(7)education, counseling, and referral including a brief written plan (e.g., a checklist or alternative) provided to the individual for obtaining the appropriate screening and other preventive services, which are separately covered under Medicare Part B (that is, pneumococcal, influenza and hepatitis B vaccines and their administration, screening mammography, screening pap smear and screening pelvic examinations, prostate cancer screening tests, colorectal cancer screening tests, diabetes outpatient self-management training services, bone mass measurements, glaucoma screening, medical nutrition therapy for individuals with diabetes or renal disease, cardiovascular screening blood tests, diabetes screening tests, screening ultrasound for abdominal aortic aneurysms, an electrocardiogram, and additional preventive services covered under Medicare Part B through the Medicare national coverage determinations process).
2.Annual Wellness Visit (AWV)
Effective January 1, 2011, Sections 1861(s)(2)(FF) and 1861(hhh) of the Social Security Act and implementing regulations at 42 CFR 410.15, authorize for an AWV providing personalized prevention plan services (PPPS). The AWV is a preventive visit available to eligible beneficiaries, and identified by HCPCS codes G0438 (Annual wellness visit, including PPPS, first visit) and G0439 (Annual wellness visit, including PPPS, subsequent visit). Information, including definitions of relevant terms and coverage requirements for the AWV are included in Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 280.5.
The first AWV providing PPPS (HCPCS G0438) is a ‘one time’ allowed Medicare benefit and includes the following elements furnished to an eligible beneficiary by a health professional:
Review (and administration if needed) of a health risk assessment,
*Establishment of the individual’s medical/family history,
*Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual,
*Measurement of the individual’s height, weight, body mass index (or waist circumference, if appropriate), blood pressure (BP), and other routine measurements as deemed appropriate, based on the individual’s medical and family history,
*Detection of any cognitive impairment that the individual may have,
*Review of an individual’s potential risk factors for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national professional medical organizations,
*Review of the individual’s functional ability and level of safety, based on direct observation of the individual, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations,
*Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and Advisory Committee of Immunizations Practices (ACIP), and the individual’s health risk assessment, health status, screening history, and age-appropriate preventive services covered by Medicare,
*Establishment of a list of risk factors and conditions of which primary, secondary, or tertiary interventions are recommended or underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits,
*Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management or community-based lifestyle interventions to reduce health risks and promote self- management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition, and,
*Any other element(s) determined appropriate by the Secretary through the
national coverage determinations process.
Subsequent AWVs providing PPPS (HCPCS G0439) include the following key elements furnished to an eligible beneficiary by a health professional:
Review (and administration, if needed) of an updated health risk assessment,
*Update of the individual’s medical/family history,
*Update to the list of current providers and suppliers that are regularly involved in providing medical care to the individual as that list was developed for the first AWV providing PPPS, or the previous subsequent AWV providing PPPS,
*Measurement of an individual’s weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on the individual’s medical and family history,
*Detection of any cognitive impairment that the individual may have,
*Update to the individual’s written screening schedule as developed at the first AWV providing PPPS,
*Update to the individual’s list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, as that list was developed at the first AWV providing PPPS, or the previous subsequent AWV providing PPPS,
*Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs, and,
*Any other element determined appropriate by the Secretary through the national coverage determinations process.
See chapter 18 of this manual for additional information regarding preventive services
that are separately covered under Medicare Part B.
B.Who May Perform an IPPE or AWV
The contractor pays the appropriate physician fee schedule amount based on the rendering National Provider Identification (NPI) number.
The IPPE may be performed by:
*a doctor of medicine or osteopathy as defined in Section 1861(r) (1) of the Social Security Act, or
*a qualified nonphysician practitioner (nurse practitioner, physician assistant or clinical nurse specialist).
The AWV may be performed by a health professional, which is defined as:
*a doctor of medicine or osteopathy as defined in Section 1861(r)(1) of the Social Security Act,
a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Social Security Act), or
*a medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician (doctor of medicine or osteopathy).
C.Eligibility
1.IPPE
Medicare pays for one IPPE per beneficiary per lifetime for beneficiaries within the first 12 months of the effective date of the beneficiary’s first Part B coverage period.
2.AWV
Medicare pays for an AWV for a beneficiary who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and who has not received either an IPPE or an AWV providing PPPS within the past 12 months. Medicare pays for only one first AWV (HCPCS G0438), per beneficiary per lifetime. All subsequent AWVs must be billed using HCPCS G0439.
D.Deductible and Coinsurance
1.IPPE
The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.
The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009. However, the applicable coinsurance continues to apply for the IPPE provided on or after January 1, 2009.
As a result of the Affordable Care Act (ACA), effective for the IPPE provided on or after January 1, 2011, the Medicare deductible and coinsurance (for HCPCS code G0402 only) are waived.
2.AWV
As a result of the ACA, effective January 1, 2011, the Medicare deductible and coinsurance for the AWV (HCPCS G0438 and G0439) are waived.
E.The EKG Component of the IPPE
The once-in-a-lifetime screening EKG may be performed, as appropriate, with a referral from an IPPE.
F.HCPCS Codes Used to Bill the IPPE or AWV
1.HCPCS Codes Used to Bill the IPPE
For IPPE and EKG services provided prior to January 1, 2009, the physician or qualified NPP shall bill HCPCS code G0344 for the IPPE performed face-to-face, and HCPCS code G0366 for performing a screening EKG that includes both the interpretation and report. If the primary physician or qualified NPP performs only the IPPE, he/she shall bill HCPCS code G0344 only. The physician or entity that performs the screening EKG that includes both the interpretation and report shall bill HCPCS code G0366. The physician or entity that performs the screening EKG tracing only (without interpretation and report) shall bill HCPCS code G0367. The physician or entity that performs the interpretation and report only (without the EKG tracing) shall bill HCPCS code G0368. Medicare will pay for a screening EKG only as part of the IPPE. HCPCS codes G0344, G0366, G0367 and G0368 will not be billable codes effective on or after January 1, 2009.
Effective for a beneficiary who has the IPPE on or after January 1, 2009, and within his/her 12-month enrollment period of Medicare Part B, the IPPE and screening EKG services are billable with the appropriate HCPCS G code(s).
The physician or qualified NPP shall bill HCPCS code G0402 for the IPPE performed face-to-face with the patient.
The physician or entity shall bill HCPCS code G0403 for performing the complete screening EKG that includes the tracing, interpretation and report.
The physician or entity that performs the screening EKG tracing only (without interpretation and report) shall bill HCPCS code G0404.
The physician or entity that performs the screening EKG interpretation and report only, (without the EKG tracing) shall bill HCPCS code G0405.
2.HCPCS Codes Used to Bill the AWV
For the first AWV provided on or after January 1, 2011, the health professional shall bill HCPCS G0438 (Annual wellness visit, including PPPS, first visit). This is a once per beneficiary per lifetime allowable Medicare Part B benefit.
All subsequent AWVs shall be billed with HCPCS G0439 (Annual Wellness Visit, including PPPS, subsequent visit). In the event that a beneficiary selects a new health professional to complete a subsequent AWV, the new health professional will continue to bill the subsequent AWV with HCPCS G0439.
NOTE: For an IPPE or AWV performed during the global period of surgery, refer to chapter 12, §30.6.6 of this chapter for reporting instructions.
G.Documentation for the IPPE or AWV
Practitioners eligible to furnish an IPPE or an AWV are required to use the 1995 and 1997 E/M documentation guidelines to document the medical record with the appropriate clinical information. (http://xmarks.com/site/www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp). All referrals and a written medical plan must be included in this documentation.
H.Reporting a Medically Necessary E/M Service Furnished During the Same Encounter as an IPPE or AWV
When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes 99201 – 99215 may be reported depending on the clinical appropriateness of the circumstances. CPT Modifier –25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whichever applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).
NOTE: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable, E/M service.
