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).

NOTE: 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.


Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service



When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a noncovered preventive medicine service (CPT codes 99381-99397), consider the covered visit to be provided in lieu of a part of the preventive medicine service of equal value to the visit. A preventive medicine service (CPT codes 99381-99397) is a noncovered service. The physician may charge the beneficiary, as a charge for the noncovered remainder of the service, the amount by which the physician’s current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit. Pay for the covered visit based on the lesser of the fee schedule amount or the physician’s actual charge for the visit. The physician is not required to give the beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit. However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury.

There could be covered and noncovered procedures performed during this encounter (e.g., screening x-ray, EKG, lab tests.). These are considered individually. Those
procedures which are for screening for asymptomatic conditions are considered noncovered and, therefore, no payment is made. Those procedures ordered to diagnose or monitor a symptom, medical condition, or treatment are evaluated for medical necessity and, if covered, are paid.

HCPCS CODE - G0402 , G0367, G0368 AND G0344

 HCPCS Codes Used to Bill the IPPE

For IPPE and EKG services provided prior to January 1, 2009, the physician or qualified NPP shall bill HCPCS code G0344 for the IPPE performed face-to-face, and HCPCS code G0366 for performing a screening EKG that includes both the interpretation and report. If the primary physician or qualified NPP performs only the IPPE, he/she shall bill HCPCS code G0344 only. The physician or entity that performs the screening EKG that includes both the interpretation and report shall bill HCPCS code G0366. The physician or entity that performs the screening EKG tracing only (without interpretation and report) shall bill HCPCS code G0367. The physician or entity that performs the interpretation and report only (without the EKG tracing) shall bill HCPCS code G0368. Medicare will pay for a screening EKG only as part of the IPPE. HCPCS codes G0344, G0366, G0367 and G0368 will not be billable codes effective on or after January 1, 2009.

Effective for a beneficiary who has the IPPE on or after January 1, 2009, and within his/her 12-month enrollment period of Medicare Part B, the IPPE and screening EKG services are billable with the appropriate HCPCS G code(s).

The physician or qualified NPP shall bill HCPCS code G0402 for the IPPE performed face-to-face with the patient.

The physician or entity shall bill HCPCS code G0403 for performing the complete screening EKG that includes the tracing, interpretation and report.

The physician or entity that performs the screening EKG interpretation and report only, (without the EKG tracing) shall bill HCPCS code G0405


 Deductible and Coinsurance
. IPPE

The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.

The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009. However, the applicable coinsurance continues to apply for the IPPE provided on or after January 1, 2009.

As a result of the Affordable Care Act (ACA), effective for the IPPE provided on or after January 1, 2011, the Medicare deductible and coinsurance (for HCPCS code G0402 only) are waived.



2. AWV

As a result of the ACA, effective January 1, 2011, the Medicare deductible and coinsurance for the AWV (HCPCS G0438 and G0439) are waived.



E. The EKG Component of the IPPE

The once-in-a-lifetime screening EKG may be performed, as appropriate, with a referral from an IPPE.

Which provider can perform IPPE And AWV - Eligibility guide

B. Who May Perform an IPPE or AWV

The contractor pays the appropriate physician fee schedule amount based on the rendering National Provider Identification (NPI) number.

The IPPE may be performed by:

• a doctor of medicine or osteopathy as defined in Section 1861(r) (1) of the Social Security Act, or

• a qualified nonphysician practitioner (nurse practitioner, physician assistant or clinical nurse specialist).

The AWV may be performed by a health professional, which is defined as:

• a doctor of medicine or osteopathy as defined in Section 1861(r)(1) of the Social Security Act,a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Social Security Act), or

• a medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of such medical professionals,
working under the direct supervision of a physician (doctor of medicine or osteopathy).


C. Eligibility

1. IPPE

Medicare pays for one IPPE per beneficiary per lifetime for beneficiaries within the first 12 months of the effective date of the beneficiary’s first Part B coverage period.


2. AWV

Medicare pays for an AWV for a beneficiary who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and who has not received either an IPPE or an AWV providing PPPS within the past 12 months. Medicare pays for only one first AWV (HCPCS G0438), per beneficiary per lifetime. All subsequent AWVs must be billed using HCPCS G0439.

Annual Wellness Visit (AWV) CPT CODE G0439, G0438

 The AWV is a preventive visit available to eligible beneficiaries, and identified by HCPCS codes G0438 (Annual wellness visit, including PPPS, first visit) and G0439 (Annual wellness visit, including PPPS, subsequent visit). Information, including definitions of relevant terms and coverage requirements for the AWV are included in Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 280.5.

The first AWV providing PPPS (HCPCS G0438) is a ‘one time’ allowed Medicare benefit and includes the following elements furnished to an eligible beneficiary by a health professional:

Review (and administration if needed) of a health risk assessment,

• Establishment of the individual’s medical/family history,

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

• 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,

• 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 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and Advisory Committee of Immunizations Practices (ACIP), and the individual’s health risk assessment, 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,

• Furnishing 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, and,

• Any other element(s) determined appropriate by the Secretary through the national coverage determinations process.

Subsequent AWVs providing PPPS (HCPCS G0439) include the following key elements furnished to an eligible beneficiary by a health professional:
Review (and administration, if needed) of an updated health risk assessment,

• Update of the individual’s medical/family history,

• Update to the list of current 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, or the previous subsequent AWV providing PPPS,

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

• 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, or the previous subsequent AWV providing PPPS,

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

• Any other element determined appropriate by the Secretary through the national coverage determinations process.

See chapter 18 of this manual for additional information regarding preventive services that are separately covered under Medicare Part B.

Basics of Initial Preventive Physical Examination (IPPE)

As described in the implementing regulations, the IPPE includes the following:

(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 the appropriate screening and other preventive services, which are separately covered 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 determinations process).

Document - Elements of Skin Exam

Skin 

Palpation of scalp and inspection of hair of scalp, eyebrows, face,
chest, pubic area (when indicated) and extremities
Inspection and/or palpation of skin and subcutaneous tissue (eg,
rashes, lesions, ulcers, susceptibility to and presence of photo
damage) in eight of the following ten areas:
Head, including the face and
Neck
Chest, including breasts and axillae
Abdomen
Genitalia, groin, buttocks
Back
Right upper extremity
Left upper extremity
Right lower extremity
Left upper extremity
NOTE: For the comprehensive level, the examination of at least eight anatomic
areas must be performed and documented. For the three lower levels of
examination, each body area is counted separately. For example, inspection
and/or palpation of the skin and subcutaneous tissue of the right upper extremity
and the left upper extremity constitutes two elements.
Inspection of eccrine and apocrine glands of skin and subcutaneous
tissue with identification and location of any hyperhidrosis,
chromhidroses or bromhidrosis

Elements of Eyes, Ear, Mouth and Throat EXAM

Eyes 

Test ocular motility including primary gaze alignment

Ears, Nose, Mouth and Throat

Otoscopic examination of external auditory canals and tympanic membranes
including pneumo-otoscopy with notation of mobility of membranes
Assessment of hearing with tuning forks and clinical speech reception
thresholds (eg, whispered voice, finger rub)
External inspection of ears and nose (eg, overall appearance, scars, lesions and masses)
Inspection of nasal mucosa, septum and turbinates
Inspection of lips, teeth and gums
Examination of oropharynx: oral mucosa, hard and soft palates, tongue,
tonsils and posterior pharynx (eg, asymmetry, lesions, hydration of mucosal
surfaces)
Inspection of pharyngeal walls and pyriform sinuses (eg, pooling of saliva, asymmetry, lesions)
Examination by mirror of larynx including the condition of the epiglottis,
false vocal cords, true vocal cords and mobility of larynx (Use of mirror not
required in children)
Examination by mirror of nasopharynx including appearance of the mucosa,
adenoids, posterior choanae and eustachian tubes (Use of mirror not required in children)

Neck 

Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)

Examination of thyroid (eg, enlargement, tenderness, mass)

Neurologic, Psyciatric, Lymphatic and Musculoskeletal - Elements of Exam

Lymphatic 

Palpation of lymph nodes in
Neck
two or more areas:
Axillae
Groin
Other

Musculoskeletal 

Examination of gait and station
Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis,
inflammatory conditions, petechiae, ischemia, infections, nodes)
Examination of joints, bones and muscles of one or more of the following six areas: 1)
head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity;
5) right lower extremity; and 6) left lower extremity. The examination of a given area
includes:
Inspection and/or palpation with notation of presence of any misalignment,
asymmetry, crepitation, defects, tenderness, masses, effusions
Assessment of range of motion with notation of any pain, crepitation or
contracture
Assessment of stability with notation of any dislocation (luxation),
subluxation or laxity
Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic)
with notation of any atrophy or abnormal movements


Neurologic
Test cranial nerves with notation of any deficits
Examination of deep tendon reflexes with notation of pathological reflexes (eg,
Babinski)
Examination of sensation (eg, by touch, pin, vibration, proprioception)


Psychiatric


Description of patient’s judgment and insight
Brief assessment of mental status including:
orientation to time, place and person
recent and remote memory
mood and affect (eg, depression, anxiety, agitation)

Elements of Gentourinary and Gastrointestinal Exam

Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence of masses or tenderness
Examination of liver and spleen
Examination for presence or absence of hernia
Examination (when indicated) of anus, perineum and rectum, including sphincter
tone, presence of hemorrhoids, rectal masses
Obtain stool sample for occult blood test when indicated


Genitourinary

MALE:
Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of
cord, testicular mass)
Examination of the penis
Digital rectal examination of prostate gland (eg, size, symmetry, nodularity,
tenderness)

FEMALE:
Pelvic examination (with or without specimen collection for smears and cultures),
including
Examination of external genitalia (eg, general appearance, hair distribution,
lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions,
pelvic support, cystocele, rectocele)
Examination of urethra (eg, masses, tenderness, scarring)
Examination of bladder (eg, fullness, masses, tenderness)
Cervix (eg, general appearance, lesions, discharge)
Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or
support)
Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)

Wellness Visit Submission Codes CPT g0402, g0438, G0439

Please submit the following code for the one-time Welcome to Medicare Visit:
• G0402

Please submit one of the following codes for the Annual Wellness Visit:
• G0438 (first visit)
• G0439 (subsequent visit)

In 2015, our plans also cover an Annual Routine Physical Examination by the member’s Primary Care Physician (PCP) and can be billed using the following codes:
• 99385-99387
• 99395-99397

Annual Routine Physical Examination coverage:

• If you bill these 99XXX codes, you must provide a head-to-toe exam and cannot bill for a separate breast and pelvic exam, a Digital Rectal Exam (DRE), or counseling to promote healthy behavior. See the Definitions section for details on the specific components included in the visit. All UnitedHealthcare Medicare Advantage plans for individuals include this benefit in 2015. Coverage on employer group Medicare Advantage plans may vary

All plans offer a Pap/Pelvic Exam (including pelvic exam and the pap collection with coverage periodicity following Medicare guidelines: covered annually for those at high risk and every two years for women not considered high risk) for a $0 copay. A separate Evaluation and Management (E/M) code may be billed only if a separately identifiable E/M service was provided. The following code is accepted:

• Exam: G0101

When members see an obstetrician or gynecologist who is not their assigned PCP for a routine pap/pelvic exam, only the Medicare-covered annual pap/pelvic service should be performed and billed. Members should be referred to their assigned PCP if a more comprehensive preventive service is warranted.