Thursday, August 11, 2011

CPT code G0402, G0403, G0404, G0405 - Medicare coverage

Initial Preventive Physical Examination (IPPE) Also known as the “Welcome to Medicare Visit”


CPT code 


G0402 – IPPE
G0403 – ECG for IPPE
G0404 – ECG tracing for IPPE 
G0405 – ECG interpret & report 


Important – The screening EKG is an optional service that may be performed as a result of a referral from an IPPE 

Covered DX

No specific diagnosis code Contact the local Medicare Contractor for guidance

All Medicare beneficiaries whose first Part B coverage began on or after 01/01/05


Frequency


Once in a lifetime benefit per beneficiary
Must be furnished no later than 12 months after the effective date of the first Medicare Part B coverage




Initial Preventive Physical Examination (IPPE) or Welcome to Medicare Preventive Visit

The Initial Preventive Physical Examination (IPPE) is also known as the 'Welcome to Medicare Preventive Visit.' The goals of the IPPE are health promotion and disease prevention and detection. This document explains the components included in the IPPE. You must provide, or provide and refer, all components of the IPPE prior to submitting a claim for the IPPE.

The Initial preventive physical examination; face-to-face visit services are limited to the new beneficiary during the first 12 the months of Medicare enrollment (G0402-Initial preventive physical examination).

The IPPE contains Seven Components:

Review of the individual's:

Medical and social history with attention to modifiable risk factors for disease detection

Potential (risk factors) for depression or other mood disorders

Functional ability and level of safety

Physical examination to include:

Measurement of the individual’s height

Weight

Blood pressure

Visual acuity screen

Measurement of body mass index; and

Other factors as deemed appropriate by the examining physician or qualified non-physician practitioner (NPP)

End of life planning, upon agreement of the beneficiary

End-of-life planning is verbal or written information provided to the beneficiary about:

The beneficiary’s ability to prepare an 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 you are willing to follow the beneficiary’s wishes as expressed in the advance directive

Based on the results of the review and evaluation services described in the previous five elements , the following would be
provided

Education

Counseling

Referral, as deemed appropriate

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

Electro-cardiogram (EKG)

MIPPA (Medicare Improvement for Patients and Providers Act) removed the screening electrocardiogram (EKG) as a mandatory service of the IPPE
Education, counseling, and referral for an EKG, as appropriate.
This is a once-in-a-lifetime screening EKG as a result of a referral from an IPPE
EKG HCPCS codes (G0403,G0404,G0405)
Annual Wellness Visit (AWV)

The AWV is an annual Medicare preventive physical examination, available for eligible beneficiaries, and identified by HCPCS codes:

G0438 (Annual wellness visit, including Personalized prevention Plan Services [PPPS], first visit)
G0439 (Annual wellness visit, including PPPS, subsequent visit)
AWV services providing PPPS (HCPCS G0438) are a ‘one time’ allowed Medicare benefit and include the following key elements furnished to an eligible beneficiary by a health professional:




Establishment of the individual’s medical/family history

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
Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual



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 five to 10 years, as appropriate, based on recommendations of the USPSTF and Advisory Committee of Immunizations Practices (ACIP), the individual’s 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



Provision 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



Subsequent AWV Services: HCPCS G0439 

Include the following key elements furnished to an eligible beneficiary by a health professional

Update to the individual’s medical /family history

Measurements of an individual’s weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individual’s medical and family history

Update to the list of the individual’s current medical 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

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

Furnish appropriate personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs

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).

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.






Medicare payment and patient payment


G0402 prior to 01/01/11:
Copayment/coinsurance applies
Deductible waived

G0402 on or after 01/01/11:
Copayment/coinsurance waived
Deductible waived

G0403, G0404, G0405:
Copayment/coinsurance applies
Deductible applies

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