G0402: Medicare Preventive VisitBy Michelle Herbert, CPC
Medicare covers a one-time Initial Preventive Physical Examination (IPPE), also referred to as the “Welcome to Medicare” visit. IPPE is a unique benefit available only to patients newly enrolled in the Medicare Program and must be received within the first 12 months of the effective date of their Medicare Part B coverage.(This is a one time benefit.)
The IPPE is a preventive physical examination and is not a “routine head to toe physical checkup” The goals of this benefit are health promotion and disease detection and include education, counseling, and referral for other screening and preventive services also covered under Medicare Part B. The IPPE is best furnished to a patient when their health status is stable and they are open to discussing preventive and screening services.
The IPPE does not include any clinical laboratory tests. The physician (doctor of medicine or osteopathy), qualified non-physician practitioner ( a physician assistant, nurse practitioner or clinical nurse specialist). These services are typically provided in a physician office. When the services are provided in a facility, the following institutions can bill:
- Hospitals for inpatients (TOB 12X) and outpatients (TOB 13X)
- Skilled Nursing Facilities for inpatients (TOB 22X)
- Rural Health Centers (TOB 71X)
- Federally Qualified Health centers (TOB 77X)
- Critical Access Hospitals (TOB 85X)
Coding procedure code G0402: Initial Preventive Physical Examination; face-to-face visit, services limited to a new patient during the first 12 months of Medicare enrollment.
The screening EKG/ ECG is billable with HCPCS code(s) G0403,G0404, or G0405, when it is a result of a referral from an IPPE. The screening EKG/ECG G-code(s) is only covered once during the patient’s lifetime, the deductible and coinsurance still applies to screening EKG (G0403, G0404, abd G0405). The IPPE code does not include other preventative services that are currently paid separately.
Although providers must report a diagnosis code on the claim, there are no specific ICD-9-CM that are required for the IPPE and EKG/ ECG screening. Providers should choose the appropriate diagnosis code, for example, diagnosis code V70.0, V70.3, or V70.9 could be considered an acceptable diagnosis.
When physicians and/or non-physician practitioner provide a significant, separately identifiable medically necessary E/M service in addition to the IPPE, they may use CPT codes 99201-99215.
The E/M code should be reported with modifier -25, to identifying the service as significant, separately identifiable. Cost sharing will apply to the E/M service.
If the primary physician does not perform a screening EKG/ ECG, as a result of the IPPE, another physician or entity may perform and/or interpret the EKG/ ECG. The referring provider should ensure that the performing provider bills the appropriate HCPCS G-code and not a CPT 93000 series, they shall document the results in the patients medical record to complete and bill for the IPPE benefit.
Should an additional medically necessary EKG in the 93000 series need to be performed on the same day as the IPPE, report the appropriate EKG CPT codes(s) with modifier -59. This will indicate that the additional EKG is a distinct procedural service.
The Medicare IPPE exam includes seven elements. The exam focuses on identifying modifiable risk factors for medical conditions that frequently affect the elderly, as well as education, counseling and referral for Medicare screening services.
The following are the seven elements of Medicare IPPE exam:
1 Review of medical and social history with attention to modifiable risk factors for disease detection.
Medical history includes, at a minimum, past medical and surgical history, including experiences with illness, hospital stays, operations, allergies, injuries, and treatments; current medications and supplements, including calcium and vitamins;
family history, including a review of medical events in the patients family, including diseases that are hereditary or place the patient at risk.
Social history includes, at a minimum, history of alcohol, tobacco, and illicit drug use, diet and physical activities.
2 Review of the patients potential risk factors for depression and other mood disorders.
This includes current and 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. The provider may select from a various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations. Many standardized screening tools are too cumbersome to use in a short office visit. One quick technique recommended by the U.S. Preventive Services Task Force (USPSTF) involves asking two questions: “over the past two weeks, have you felt down, depressed or hopeless?’ and “Over the past two weeks, have you felt little interest or pleasure in doing things?” An affirmative answer to either may be as effective as more detailed instruments identifying a patient who needs further evaluation for depression.
3.Review of functional ability and level of safety
The provider has a lot of leeway with this element, which requires an evaluation of the patient’s hearing, activities of daily living, functional ability and level of safety.
For determining fall risk, according to the AGS (American Geriatrics Society), there are two tests that should trigger further patient evaluation: if your patient previously has received treatment for a fall, or if your patient takes longer than 30 seconds for an “Up & Go” test.
The timed Up & Go test involves having the patient stand up from a chair, walk three meters, turn around, walk back to the chair and sit back down. If the patient takes longer then 30 seconds or seems unsteady, the test is considered positive for increased fall risk.
To identify functional challenges, the CDC advises screening your patients by inquiring about their instrumental activities of daily living (IADLs). This involves asking patients about troubles using a phone, using transportation, grocery shopping, preparing meals, doing housework, doing laundry, taking medications and managing money. Any limitation to their IADLs that you identify as being caused by a chronic condition warrants further evaluation.
The CDC recommends that elderly patients improve home safety by removing tripping hazards in walkways, using non-slip mats in bathtubs and showers, placing grab bars next to the toilet and shower, placing handrails on both sides of a stairway and improving home lighting. It seems reasonable to question patients about these items during the initial preventive physical exam.
For the hearing evaluation, you can follow the USPSTF’s recommendation to simply question patients about their hearing function. There are, of course, more elaborate testing methods, but the USPSTF found insufficient evidence to recommend for or against them.
Your screening for depression risk, functional ability and level of safety should be accompanied by further evaluation, including a full diagnostic workup, for any patients with positive responses. The workup can be performed in conjunction with the initial preventive physical exam, or the patient can be further evaluated later. CMS will allow a level-one or level-two E/M code with a -25 modifier attached to be billed with the initial preventive physical exam. If you conclude that the depression or fall risk does not warrant immediate care but will require a level-three or higher E/M service, it might be prudent to perform the full workup at a later date.
4. An Examination
A focused physical exam. This should be an extremely focused physical exam. Height, weight, blood pressure, body mass index, and visual acuity are the only required components. No specific vision tests are mandated, but using the Snellen chart is appropriate.
5. End-of-life planning
End of life planning is as required service, upon the patient’s consent. End of life planning is a verbal or written information provided to the beneficiary regarding the patient’s ability to prepare and advance directive in the case that an injury or illness causes the beneficiary to be unable to make health care decisions, and whether or not the physician is willing to follow the patient’s wishes as expressed in the advance directive.
6. Education, counseling, and referral based on the previous five components
Brief education, counseling and referral to address any pertinent health issues identified during the first five elements of the exam (e.g diet, chronic illness, and smoking or alcohol use). CMS expects the amount of time required for this step to vary depending on the problems that you discovered in the first five elements.
7. Education, counseling, and referral for other preventive services
Brief education, counseling and referral, with maintenance of a written plan (such as a checklist), regarding separate preventive care services covered by Medicare Part B. There are now 11 preventive services authorized under Medicare Part B. Other covered preventive that are performed may be billed in addition to HCPCS code G0402 and the appropriate EKG G-code (influenza vaccine, mammogram, ect.)
Performance and interpretation of an electrocardiogram. Some offices have the capacity to handle this, and others will need to send the patient to another facility. Either way, the EKG/ECG results need to be incorporated into your patient’s medical record to complete the initial preventive physical exam.
If the patient is sent to another facility for the EKG/ ECG, the order must read “EKG/ECG as part of the Welcome to Medicare Physical, codes G0366–G0368.” Medicare has instructed that physicians must order the EKG/ECG in a manner that helps to prevent use of codes for EKG/ECGs not related to the initial preventive physical exam.
PREVENTIVE SERVICES COVERED BY MEDICARE PART B
- Pneumococcal, influenza and hepatitis B vaccines
- Screening mammography
- Screening Pap smear/pelvic exam
- Prostate cancer screening
- Colorectal cancer screening
- Diabetes outpatient self-management training services
- Bone mass measurements
- Screening for glaucoma
- Medical nutritional therapy for individuals with diabetes or renal disease
- Cardiovascular screening blood tests
- Diabetes screening tests
It is important that you thoroughly understand Medicare’s policy on these services before counseling your patient. Some services are covered at 100 percent of the Medicare allowable charge, and some services are covered at 80 percent of the Medicare allowable charge. In addition, some of the services are covered only if medically indicated. The IPPE will be paid at the appropriate physician fee schedule based on the rendering National Provider Identification (NPI) number.
For additional information see the following links:
ABC’s of Providing the Initial Preventive Physical Examination
Guide to Medicare preventive services
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