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.
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