A subscriber enrolled to Medicare Part B has a “Welcome to Medicare” service – Initial Preventive Physical Examination (IPPE). This service will be covered once in a lifetime within first 12 months after enrollment. There are certain components that must be provided to the patient in order to submit a claim for the service.

What are those components?

• Medical and social history
• Potential risk factors for depression and other mood disorders
• Functional ability and level of safety
• Exam, including height, weight, BMI, blood pressure, visual acuity screen, other factors deemed appropriate based on above points and current clinical standards
• End-of-life planning, on agreement of the beneficiary.
• Educate, counsel and refer based on the previous components
• Educate, counsel and refer for other preventive services, for example ECG, if appropriate

What are the codes?

The IPPE itself coded as G0402. A diagnostic electrocardiogram (ECG/EKG) codes – G0403, G0404 and G0405 – complete, technical only and professional only components respectively. ECG coded G0403, G0404 or G0405 is also once in a life benefit.

Diagnosis

There is no specific diagnosis required to be reported on the claim with IPPE. Any consistent code may be applied. If no documented diagnoses for the patient, you may choose, for example, diagnosis Z00.00

Who is eligible to perform?

IPPE will be covered by Medicare if performed by:

• Physician – MD or DO
• Qualified non-physician practitioner (a physician assistant, nurse practitioner or certified clinical nurse specialist).

 Does deductible or coinsurance/copayment apply for the service?

No deductible or coinsurance/copayment applies for the IPPE.  

However, it does for diagnostic ECG.

After receiving an IPPE patient becomes eligible for Annual Wellness Visit (AWV) 12 months following the IPPE. Medicare will cover AWV if:

• The patient was enrolled to Medicare Part B more than 12 months ago
• The patient have not received IPPE or AWV within past 12 months

Initial AWV has expanded components list, including administration of HRA – Health Risk Assessment. HRA is a list of questions, which provider or the patient can complete before or during the AWV encounter.

During initial AWV a written screening schedule for the patient must be established for the next 5-10 years.   

Subsequent AWV mostly requires provider just to update existing HRA and other components and medical information from initial AWV.    

What are the codes?

For an initial AWV – G0438, for a subsequent – G0439.

Diagnosis

Same requirements as for an IPPE.

Who is eligible to perform?

AWV will be covered by Medicare if performed by:

• Physician – MD or DO
• Qualified non-physician practitioner (a physician assistant, nurse practitioner or certified clinical nurse specialist)
• Medical professional (health educator, registered dietitian, nutrition professional or other licensed professional) or a team of medical professionals who are directly supervised by MD or DO.

Does deductible or coinsurance/copayment apply for the service?

No deductible or coinsurance/copayment applies for the AWV.

Advance Care planning (ACP) can be furnished separately or as an element of AWV. It is the face-to-face conversation between a patient and a provider to determine patient’s wishes or preferences in case he or she is unable to speak or take decisions. This talk could be uncomfortable and difficult for the beneficiary, so family members may participate as well.   

What are the codes?

First 30 minutes of ACP – 99497, each additional 30 minutes – 99498. Procedure code 99497 can be reported if the ACP continues at least 16 minutes.

Diagnosis

Same requirements as for an IPPE and AWV.

Does deductible or coinsurance/copayment apply for the service?

The deductible and coinsurance are waived for ACP only once per year and only when it is billed with AWV – by the same provider, with 33 modifier and in the same claim with AWV. In case AWV is denied, deductible and coinsurance will be applied for ACP. When ACP provided separately of AVW deductible and coinsurance applies as well.

There are different options to check if beneficiary already got his/her AWV from another provider – you may call Interactive Voice Responses (IVR) or send inquiry through HETS – HIPAA Eligibility Transaction System. There could be other options provided by specific Medicare Administrative Contractor (MAC) – contact NGS for New York and Novitas Solution for New Jersey.