Documentation Criteria: Medicare Physicals

by  Jeanette Anderson, CPC, CPMA
May 27th, 2016

When billing annual Medicare physicals, it's very important to know the status of the patient, determining when they became eligible, and/or if they've seen another provider for any of these services as the initial visit codes are once in a lifetime codes and will be denied if they have already been billed for that particular patient. This information can be found by researching the patient's benefits on the Medicare website, www.medicare.gov.

Starting from the beginning, the Welcome to Medicare visit (G0402) also known as the Initial Preventive Physical Exam (IPPE) is Medicare's preventive E/M face to face visit. This code can only be used for the first twelve months from the date the patient became Medicare eligible. With this code, there are also additional initial screening EKG codes (G0403-G0405) that are also once in a lifetime codes. It is allowable to bill a regular EKG code if, for example, while taking a patients' vital signs palpitations were found. In this instance, medical necessity would support billing a regular EKG code (93000-93010).

Below are the documentation criteria that need to be met to support billing a G0402. These criteria are mostly verbal, aside from the exam:

Beyond the Initial Preventive Physical (IPPE) time frame (12 months), you would move into billing for Medicare Annual Wellness Visits. This process begins with the once in a lifetime code G0438, known as the Initial Annual Wellness Visit which includes a personalized prevention plan of service (PPPS).

Below are the documentation criteria that need to be met to support billing a G0438. These criteria are mainly an overview and establishing patient history and well being:

Twelve months beyond the Initial Medicare Annual Wellness Visit would be the subsequent visit, or code G0439. This code would also include a personalized prevention plan of service (PPPS). Below are the documentation criteria that need to be met to support billing a G0439. These criteria provide updates to everything previously captured in the initial wellness visit:

These codes are very different from your age-based periodic Comprehensive Preventative Visit (codes 99387 and 99397), which are not covered by Medicare. These Medicare physicals are heavily focused on record keeping of medical history and updates of the patient's wellbeing, focusing on preventive care. These physicals do not include clinical lab tests or screening which would be separately reportable. In addition, these codes can also be billed with a sick visit. For example, if a patient comes in for his/her annual wellness visit but also with complaints of abdominal pain, with enough documentation to support a significant separately identifiable E/M, the appropriate level of E/M with modifier 25 could be billed in addition to the Medicare physical.

Documentation Criteria: Medicare Physicals. (2016, May 27). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/documentation-criteria-medicare-physicals-31726.html

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