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“Welcome to Medicare Visit” aka IPPE aka G0402

Health Insurance Companies Process 1 in 5 Claims Wrong

Initial Preventative Physical Exam (IPPE) G0402 is Known 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 to explain and to point you in the right direction for 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 who can schedule 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

Medicare EKG G0403 93000Screening 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.

Medicare pneumococcal Vaccine 90669 90670 90732Pneumococcal Vaccine – This vaccine is also considered a once-in-a-lifetime benefit, but additional vaccinations may also be allowed only once every five years, based on patient risk. Beneficiary’s copayment/coinsurance/deductible is waived. This does not need to be billed out with the IPPE, but it is highlighted here because of the once-in-a-lifetime benefit stipulation.

Who should be immunized?
If a beneficiary is uncertain about his 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 www.CMS.com.

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 www.CMS.com.

I 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.

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15 Responses to ““Welcome to Medicare Visit” aka IPPE aka G0402”

  1. Since November, 2016, I have consistently been getting denials from Medicare for G0444 when billed with G0439. I’ve called the JH region on separate occasions and all the Medicare reps tell me it needs to be billed with a modifier, but my understanding was that no modifier was needed with G codes. Ive tried 33, 25, 59 to no avail. These depression screenings were always covered before November 2016. Is there a new Medicare rule on this code that I’m not aware of?

    Reply
  2. in order to code G0444 (and other G codes such as G0442) do I need to spend an additional 15 minutes with the patient to code for this, or is up to(including less than) 15 minutes? Thank you

    Reply
  3. Manny,
    I know there is a way to look up online (CMS.gov?) what G codes a patient is eligible for and which have been already billed out over the past year, but I cannot figure out how to do it. I know you can print out everything related to that patients benefits including what G codes haven’t been billed out yet. Do you know where and how to do this? Thank you!
    Dr. Andrea
    [email protected]

    Reply
  4. Manny: I am getting patients who have just turned 65 years old, and have signed up for Medicare Part A, but are still working so they have not signed up for Part B. Does their sign-up for Part A, and eligibility by age for Part B, start the clock so that within 12 months they have to have their G0402 the Welcome to Medicare Exam, use it or lose it? Or when does that clock start for those who sign up for Part A, the free part of Medicare, but haven’t signed up for Part B and probably won’t sign up for part B until they reach Social Security full retirement age of 66? If they get the G0402 later, how do I code it so the insurance will know it came later–a modifier of some sort?

    Reply
    • Lauretta —

      My understanding is that the 12 month period starts when the patient signs up for Part B. Your local Medicare carrier should have documentation on this for you.

      Reply
    • Yes Christina you can bill a 99213 with a G0444 (annual depression screening, 15 minutes) just as long as the 99213 is for a separate issue. Make sure you document both services well.

      Reply
  5. When using G0402 do I enter 0.01 for the charge, same as other G codes?

    Reply
  6. If client is billed G0438 or G0439—are those the annual wellness exams that Medicare provides free after the first year—and every year subsequent?
    Thanks,
    Pam

    Reply
  7. I need help with usage of cpt code G0434 , We have been billing to Medicare G code with a valid clia as i have chcked the validation of clia from hippaspace.com ,but they are denying the code for invalidity of clia number. Please adivise!

    Reply

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