Help Patients Get the Most out of Their Initial Preventive Physical Examination

“Prevention and early detection” are some of the current “buzz words” in healthcare.  It is for good reason.  Statistics continually show that early detection of disease equals better outcomes, while some diseases are “headed off at the pass” by following recommended preventive measures.  Both of these also contribute to lowering medical costs for payers and patients.  This is a win-win situation all the way around.

In order to facilitate prevention and early detection, many such provisions were added into the “Obamacare law”, The Patient Protection and Affordable Care Act.  Prior to the ACA, CMS had established coverage policies regarding preventive services for its beneficiaries.

One of the crucial preventive services is the Initial Preventive Physical Examination (IPPE). This evaluation and management service is provided to a new Medicare beneficiary within the first 12 months of coverage.

The IPPE should not be confused with the Annual Wellness Visit (AWV) that is provided annually after the first 12 months of beneficiary coverage.  HCPCs Codes G0438 and G0439. Click here for further details on the AWV.

There are 7 components that must be satisfied in order for a provider to consider the visit an IPPE:

1. A review of an individual's medical and social history with attention to modifiable risk factors,

2. A review of an individual's potential (risk factors) for depression,

3. A review of the individual's functional ability and level of safety,

4. An examination to include an individual's height, weight, blood,

5. Performance of an electrocardiogram (EKG) and interpretation of the EKG,

6. Education, counseling, and referral based on the results of the review and evaluation services described in the previous five elements, and

7. Education, counseling, and referral (including a brief written plan such as a checklist provided to the individual for obtaining the appropriate screenings and other preventive services that are covered as separate Medicare Part B benefits).  

  In item 7 above, it mentions referral for covered preventative services.  The Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) – HCPC G0389 requires that the “referral” be directly as a result of an IPPE visit.  In order for the ultrasound to be covered, the IPPE must be on record with CMS and the claim indicates that the service was referred by the clinician at the time of the IPPE.

You can click here for an easy to follow comprehensive chart of all covered preventive services.

At the time of the IPPE, the healthcare professional may choose to provide some of the recommended preventative services to the patient.  These services can be billed to Medicare in addition to the IPPE as separate, payable services.

1.       Adult immunizations such as: influenza and pneumococcal.  For information on coding for these services click here.

2.       Smoking and tobacco-use cessation counseling.  For information on coding for this service click here.

3.       Human Immunodeficiency Virus (HIV) Screening.  For information on coding for this service click here.

4.       Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse.  For information on coding for these services click here.

 Learn about Billing for the IPPE:

To get reimbursed for the IPPE, submit HCPCS code, G0402.  By definition in number 5 above, this benefit always includes a screening EKG.

To get reimbursed for the screening EKG, submit one of the following HCPCS codes:

1.       If providing the full global EKG service - G0403 (Electrocardiogram, routine ECG with 12 leads; performed as a component of the initial preventive examination with interpretation and report)

2.       If providing only the tracing technical component - G0403 (tracing only, without interpretation and report; performed as a component of the initial preventive examination)

3.       If providing only the interpretation and report professional component – G0405 (interpretation and report only, performed as a component of the initial preventive examination) when only the interpretation and report are performed.

Many elements covered in the performance of the IPPE are shared with the standard evaluation and management services (CPTs 99201-99215).  During the IPPE, if the provider determines there is a medically necessary reason to perform additional care to treat an illness or injury, a separate E and M code can be submitted with an appended -25 modifier.

 The Part B deductible and coinsurance/copaymentdo not apply to the IPPE benefit for code G0402.