“Welcome to Medicare Visit” aka IPPE aka G0402

Initial Preventative Physical Exam (IPPE) G0402 is know as the “Welcome to Medicare Visit” to most Medical Billers

What is a Welcome to Medicare visit and how do you bill for it?  Let’s see if I can help and explain and point you in the right direction to gather more information.

A patient who has just qualified for Medicare Part B is allowed this once in a lifetime benefit within the first 12 months of Medicare eligibility.  Medicare calls this exam the Initial Preventative Physical Exam or IPPE but it is more widely known as the “Welcome to Medicare Visit”. This is a great benefit that also includes several exams that are normally not covered. A properly trained front desk staff scheduling appropriate appointments is essential, for both your office and for your newly Medicare eligible patient, to properly utilize these once in a lifetime benefits.

The IPPE is designed for “health promotion and disease detection” per Medicare. The following requirements of the IPPE can found at the CMS website at: http://www.cms.gov/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf

What are the requirements of the IPPE? The following requirements must be met in order to bill for the IPPE:

• Review of medical and social history to include past medical/surgical history; current medications and supplements; family history; history of alcohol; tobacco and illicit drug use; diet; and physical activities

• Review of potential risk factors for depression and other mood disorders

• Review of functional ability and level of safety for hearing impairment; activities of daily living; falls risk; and home safety

• Examination to obtain height, weight and blood pressure; visual acuity screen; measurement of body mass index; and other factors deemed appropriate based on the beneficiary’s medical/social history and current clinical standards

• End of life planning is a required service with the patient’s consent to discuss an advance directive; and whether or not the physician is willing to follow the beneficiary’s wishes as expressed in the advance directive

• Education, counseling and referral based on the previous five components, as appropriate

• Education, counseling and referral for other preventive services in the form of a brief written plan for the beneficiary to obtain a screening electrocardiogram and any other preventive services/screenings covered by Medicare Part B benefits

The IPPE is billed out using HCPCS Code G0402.

Additional once in a lifetime benefits in conjunction with the IPPE

Screening Electrocardiogram (EKG) – Medicare no longer deems the screening EKG as a mandatory service component of the IPPE. However, there is a once in a lifetime screening EKG that is allowed as a result of a referral from an IPPE and must be performed at the time of the IPPE. The screening EKG and IPPE must both be completed before they can be billed to Medicare and the beneficiary will be responsible for any copayment, coinsurance or deductible that is assessed by Medicare.

• G0403 Complete screening EKG with 12 leads; for IPPE that includes the tracing, interpretation and report (copayment/coinsurance/deductible applies)

• G0404 Screening EKG with 12 leads; tracing only without interpretation and report (copayment/coinsurance/deductible applies)

• G0405 Screening EKG with 12 leads; interpretation and report only, without tracing

See the rules for the IPPE screening EKG provided in the Medicare Claims Processing Manual at: http://www.cms.gov/manuals/downloads/clm104c12.pdf

Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) – patient must receive a referral for an AAA ultrasound screening as a result of an IPPE and must meet the criteria to have this screening ordered. Medicare will pay for this once in a lifetime benefit as long as your patient meets the following requirements:

• Beneficiaries at risk that have a family history of AAA

• Men age 65 to 75 who have smoked at least 100 cigarettes in their lifetime

The HCPCS code for the AAA is G0389 and the beneficiary’s copayment/coinsurance, deductible is waived.

Pneumococcal Vaccine – This vaccine is also considered a once in a lifetime benefit but additional vaccinations based on risk and only once every five years may also be allowed. Beneficiary’s copayment/coinsurance, deductible is waived. This does not need to be billed out with the IPPE but highlighted here because of the once in a lifetime benefit stipulation.

Who should be immunized?
If a beneficiary is uncertain about their vaccination history in the past five years then it is recommended that the vaccine be given. It is also recommended that persons 65 years of age or older and anyone considered high risk be immunized.

Who else is considered to be at increased risk?
According to the Advisory Committee on Immunization Practices (ACIP), that advises the Department of Health and Human Services, the following groups are considered high risk and should receive the initial pneumococcal vaccine or revaccination every five years:

• Persons 2 years of age and older with a normal immune system who have a chronic illness such as: cardiovascular or pulmonary disease, diabetes, alcoholism, chronic liver disease, cerebrospinal fluid leak, cochlear implant

• Immuno-compromised persons 2 years of age and older who have: splenic dysfunction, Hodgkin disease, lymphoma, multiple myeloma, chronic renal failure, nephritic syndrome, organ transplantation, immunosuppressed from chemotherapy or high dose corticosteroid therapy, asymptomatic/symptomatic HIV infection

See additional information at: http://www.cms.gov/AdultImmunizations/Downloads/20102011ImmunizersGuide.pdf

Bill for the Pneumococcal Vaccine with the following applicable codes plus the Administration of the vaccine G0009:

• 90669 Pneumococcal Conjugate Vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use

• 90670 Pneumococcal Conjugate Vaccine, 13 valent, for intramuscular use

• 90732 Pneumococcal Polysaccharide Vaccine, 23 valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use

o Use diagnosis code V03.82 for just the Pneumococcal vaccination visit
o Otherwise use diagnosis code V06.6 when the purpose of visit was to receive both pneumococcal and seasonal influenza virus vaccines.

Additional information regarding immunization can be found at:
http://www.cms.gov/MLNProducts/downloads/adult_immunization.pdf

Hope this information helps.  Please go to the top of the page and Google +1 me and leave me a message below. I would like to hear your comments, thoughts and what is happening in your medical practice.