Coding Medicare Initial Preventive Physical Exams (IPPE)

February 12th, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Categories:   CPT® Coding   HCPCS Coding   Modifiers   Diagnosis Coding   Medicare   Audits/Auditing   Billing  
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The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward.

Purpose

An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they aren’t acutely injured or ill. It facilitates discussion about the patient’s medical, social, and family history for the purpose of identifying areas of risk and ways to reduce those risks through Medicare-covered preventive services and follow-up encounters. Additionally, it helps Medicare identify and plan appropriate funding for potential risks and the care that may be required for them.

Timeline Restrictions

The IPPE is a once-in-a-lifetime benefit that must be performed within the first 12 months of the effective date of the beneficiary’s Medicare Part B Coverage. Even if a beneficiary re-enrolls in Medicare, they will never be eligible for a second opportunity to have an IPPE.

Required Documentation Points

The documentation must identify the physician and/or qualified healthcare professional (QHP) who performed (or performed and referred), all seven of the following required components of the IPPE:

  1. Review beneficiary's history to identify potential areas of risk
    • Past Medical History (illnesses, surgeries, hospitalizations, allergies, medications, etc.)
    • Family History (relationships (eg, parents, siblings, spouses, children) identifying ages, health status, who has passed away and from which illnesses or hereditary conditions
    • Social History: interactions and activities such as substance use or abuse (eg., opioid use), education level, dietary habits, legal issues, military or employment activities, level of physical exercise and activity
  2. Review and Identify potential risk factors for depression or other mood disorders
    • Identify and employ appropriate screening instruments  (see Screening Tools).
  3. Review the beneficiary's functional ability and safety level
    • Activities of daily living, fall risk, hearing impairment, and home safety.
  4. Physical Examination
    • Vital signs (eg, HT, WT, BMI, blood pressure), visual acuity, other organ systems as deemed appropriate based on history.
  5. End-of-Life Planning
    • Appropriate information (verbal or written) pertaining to any advance directives, beneficiary's wishes in case of emergency, illness, or injury and identification of anyone in particular who can make medical decisions if they cannot.
  6. Education and Counseling
    • Based on findings during the encounter, provided patient education, instruction, counseling, and appropriate referrals.
  7. Explain Medicare-covered preventive services and make appropriate referrals
    • Identify appropriate screenings, create a checklist and timeline for the beneficiary to accomplish them (eg, screening ECG).
    • Refer patient for appropriate Medicare-covered preventive services.
    • Educate patient on Medicare's Annual Wellness Visit for the following year.

Coding the IPPE and IPPE-Related Services

Because this is a special type of encounter, Medicare has created a set of HCPCS codes to report them and any appropriate ICD-10-CM code is acceptable as well: 

  • ICD-10-CM  Any appropriate ICD-10-CM is reportable, including Z-codes on the "not first-listed codes approved list" (eg., Z00.0-, Z23). The provider may also report any diagnoses or conditions identified during the IPPE. 
  • CPT/HCPCS
    • IPPE Encounter
      • G0402 IPPE (face-to-face) with new Medicare Part B enrollment (first 12 months) 
    • ScreeningECG: Although not a required component, the opportunity to get ascreeningECG for a baseline on the patient is a great health management tool. The following codes describe the global and breakoutECG services and, as such, do not need modifiers TC or 26.
    • Other preventive services, approved and paid for by Medicare Part B, can be located in the Medicare Claims Processing Manual, Chapter 18, and may be performed or ordered at the same time as the IPPE and are separately payable.

Tip: If another provider or entity performs and/or interprets the ECG from the IPPE encounter, it is still reported using the G-codes noted above; however, if the ECG is ordered due to medical necessity for another condition, it should be reported using the correct 93000 series code (93000, 93005, 93010) plus modifier 59 to distinguish it as a distinct procedure and the normal deductible and coinsurance fees will apply.

In this time of Risk Adjustment (HCC) Coding, it is important more than ever before to get to know your new Medicare beneficiaries and begin assigning the correct HCC categories to them. Look for the new Medicare beneficiaries, check their Part B effective date, and get them in for their IPPE  encounter and see how you can be an integral part of a healthy future for them.

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