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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


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Initial Preventive Physical Examinations

The initial preventive physical examination (IPPE), or “Welcome to Medicare Preventive Visit” is a preventive visit authorized by the Social Security Act.

Medicare will pay for only one IPPE per beneficiary per lifetime. The Common Working File (CWF) will edit for this benefit.

IPPE includes the following:

    • Review of the individual’s medical and social history with attention to modifiable risk factors for disease detection,

    • Review of the individual’s potential (risk factors) for depression or other mood disorders,

    • Review of the individual’s functional ability and level of safety,

    • 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,

    • End-of-life planning, upon agreement of the individual,

    • Education, counseling, and referral, as deemed appropriate, based on the results of the review and evaluation services described in the previous 5 elements, and

    • 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).

Initial Preventive Physical Examination (IPPE)

The IPPE may be performed by a doctor of medicine or osteopathy or by a qualified nonphysician practitioner (NPP) (physician assistant, nurse practitioner, or clinical nurse specialist), not later than 12 months after the date the individual’s first coverage begins under Medicare Part B.

The IPPE does not include other preventive services that are currently separately covered and paid 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 determination process.

EKG as a Component of the IPPE

If the EKG performed as a component of the IPPE is not performed by the primary physician or qualified NPP during the IPPE visit, another physician or entity may perform and/or interpret the EKG. The referring physician or qualified NPP needs to make sure that the performing physician or entity bills the appropriate G code for the screening EKG, and not a CPT code in the 93000 series. Both the IPPE and the EKG should be billed in order for the beneficiary to receive the complete IPPE service. Effective for dates of service on and after January 1, 2009, the screening EKG is optional and is no longer a mandated service of an IPPE if performed as a result of a referral from an IPPE.

Should the same physician or NPP need to perform an additional medically necessary EKG in the 93000 series on the same day as the IPPE, report the appropriate EKG CPT code(s) with modifier 59, indicating that the EKG is a distinct procedural service.

Healthcare Common Procedure Coding System (HCPCS) Coding for the IPPE

The HCPCS codes listed below were developed for the IPPE benefit effective January 1, 2005, for individuals whose initial enrollment is on or after January 1, 2005.

G0344: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 6 months of Medicare enrollment

Short Descriptor: Initial Preventive Exam

G0366: Electrocardiogram, routine ECG with 12 leads; performed as a component of the initial preventive examination with interpretation and report

Short Descriptor: EKG for initial prevent exam

G0367: tracing only, without interpretation and report, performed as a component of the initial preventive examination Short Descriptor: EKG tracing for initial prev

G0368: interpretation and report only, performed as a component of the initial preventive examination

Short Descriptor: EKG interpret & report preve

The following new HCPCS codes were developed for the IPPE benefit effective January 1, 2009, and replaced codes G0344, G0366, G0367, and G0368 shown above beginning with dates of service on or after January 1, 2009:

G0402: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment

Short Descriptor: Initial Preventive exam

G0403: Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

Short Descriptor: EKG for initial prevent exam

G0404: Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

Short Descriptor: EKG tracing for initial prev

G0405: Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Short Descriptor: EKG interpret & report preve

Facilities and Settings

A/B MACs (A) will pay for IPPE or EKG only when the services are submitted on one of the following TOBs: 12X, 13X, 22X, 71X, 73X and 85X.

Type of facility and setting determines the basis of payment:

    • For the IPPE or the screening EKG tracing only performed on a 12X and 13X TOB, hospital inpatient Part B and hospital outpatient, for hospitals subject to the outpatient prospective payment system (OPPS), under the OPPS. Hospitals not subject to OPPS shall be paid under current methodologies.
    •  For services performed on an 85X TOB, Critical Access Hospitals (CAHs), pay on reasonable cost.
    • For services performed in a skilled nursing facility, TOB 22x, make payment for the technical component of the EKG based on the MPFS.
    •  For inpatient or outpatient services in hospitals in Maryland, make payment according to the Health Services Cost Review Commission.
    • For services performed on a 12X TOB, Indian Health Services (IHS) hospitals, payment is made based on an all-inclusive ancillary per diem rate.
    • For services performed on a 13X TOB, IHS hospitals, payment is made based on the all-inclusive rate (AIR).
    • For services performed on an 85X TOB, IHS CAHs, payment is made based on an all-inclusive facility specific per visit rate.

All CAHs are paid for the technical or facility component of the IPPE itself. They are also paid for the technical component of the EKG, the tracing only, if the EKG is performed. Only CAHs paid under the optional method are paid for the professional component of the IPPE itself (in addition to the facility payment) for charges under revenue code 0960. If the EKG is performed, CAHs paid under the optional method may also be paid for the interpretation of the EKG (in addition to the payment for the tracing) when billed under revenue codes 0985 or 0986.



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