by Jared Staheli
July 5th, 2015
(NOTE: For billing and payment requirements for the Annual Wellness Visit, see chapter 18, section 140, of this chapter.)
Background: 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)) authorize coverage under Part B for a one-time initial preventive physical examination (IPPE) for new Medicare beneficiaries that meet certain eligibility requirements.
Coverage: As described in implementing regulations at 42 CFR 410.16, 411.15(a)(1), and 411.15(k)(11), the IPPE may be performed by a doctor of medicine or osteopathy as defined in section 1861 (r)(1) of the Social Security Act (the Act) or by a qualified nonphysician practitioner (NPP) (physician assistant, nurse practitioner, or clinical nurse specialist), not later than 12 months after the date the individual’s first coverage begins under Medicare Part B. (See section 80.3 for a list of bill types of facilities that can bill A/B MACs for this service.)
The IPPE includes:
(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 appropriate screening and other preventive services, which are separately covered under Medicare Part B.
Medicare will pay for only one IPPE per beneficiary per lifetime. The Common Working File (CWF) will edit for this benefit.
The IPPE does not include other preventive services that are currently separately covered and paid 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 determination process.)
For the physician/practitioner billing correct coding and payment policy, refer to chapter 12, section 220.127.116.11, of this manual.