MLN6775421 – Medicare Wellness Visits

The Initial Preventive Physical Exam (IPPE), also known as the Welcome to Medicare Preventive Visit, promotes good health through disease prevention and detection. We pay for 1 patient IPPE per lifetime no later than the first 12 months after the patient’s Part B benefits eligibility date.

Appropriate screenings and other preventive services we cover

Include a brief written plan, like a checklist, for the patient to get:

9. Educate, counsel, and refer for other preventive services

Based on the review and evaluation services results in the previous components, provide appropriate education, counseling, and referrals.

Review the patient’s potential SUD risk factors and, as appropriate, refer them to treatment. You can use a screening tool, but it’s not required. National Institute on Drug Abuse Screening and Assessment Tools Chart has screening and assessment tools.

HHS Pain Management Best Practices Inter-Agency Task Force Report has more information.

Refer to a specialist, as appropriate

If you (their physician or practitioner) agree to follow their advance directive

Their ability to prepare an advance directive in case an injury or illness prevents them from making health care decisions

End-of-life planning is verbal or written information offered to the patient about:

Other factors deemed appropriate based on medical and social history and current clinical standards

Height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure

Use direct patient observation, or appropriate screening questions or standardized questionnaires recognized by national professional medical organizations, to review, at a minimum, these areas:

Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. Depression Assessment Instruments webpage has more information.

2. Review patient’s potential depression risk factors, including current or past experiences with depression or other mood disorders

SBIRT Services booklet has more information about Medicare substance use disorder (SUD) services coverage.

Family history (review patient’s family and medical events, including hereditary conditions that place them at increased risk)

Coding

Use these HCPCS codes to file IPPE and ECG screening claims:

G0402

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

G0403

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

G0404

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

G0405

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

G0468*

Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv

* Section 60.2 of Medicare Claims Processing Manual, Chapter 9 has more information on how to bill HCPCS code G0468.

Diagnosis

You must report a diagnosis code when submitting IPPE claims. We don’t require you to use a specific IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Billing

Part B covers an IPPE when performed by a:

• Physician (doctor of medicine or osteopathy)

• Qualified non-physician practitioner (NPP) (physician assistant [PA], nurse practitioner [NP], or certified clinical nurse specialist [CCNS])

When you provide an IPPE and a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205 and 99211–99215) with modifier –25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

CPT only copyright 2022 American Medical Association. All rights reserved.