(Medicare Claims Processing Manual)

1. IPPE   The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.   The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009.  However, the applicable coinsurance continues to apply for the IPPE provided on or after January 1, 2009.   As a result of the Affordable Care Act (ACA), effective for the IPPE provided on or after January 1, 2011, the Medicare deductible and coinsurance (for HCPCS code G0402 only) are waived.   2. AWV   As a result of the ACA, effective January 1, 2011, the Medicare deductible and coinsurance for the AWV (HCPCS G0438 and G0439) are waived.  E. The EKG Component of the IPPE   The once -in-a-lifetime screening EKG may be performed, as appropriate, with a referral from an IPPE.   F. HCPCS Codes Used to Bill the IPPE or AWV  1. HCPCS Codes Used to Bill the IPPE   For IPPE and EKG services provided prior to January 1, 2009, the physician or qualified NPP shall bill HCPCS code G0344 for the IPPE performed face -to-face, and HCPCS code G0366 for performing a screening EKG that includes both the interpretation and repor t.  If the primary physician or qualified NPP performs only the IPPE, he/she shall bill HCPCS code G0344 only.  The physician or entity that performs the screening EKG that includes both the interpretation and report shall bill HCPCS code G0366.  The physi cian or entity that performs the screening EKG tracing only (without interpretation and report) shall bill HCPCS code G0367.  The physician or entity that performs the interpretation and report only (without the EKG tracing) shall bill HCPCS code G0368. Me dicare will pay for a screening EKG only as part of the IPPE.  HCPCS codes G0344, G0366, G0367 and G0368 will not be billable codes effective on or after January 1, 2009.   Effective for a beneficiary who has the IPPE on or after January 1, 2009, and within his/her 12-month enrollment period of Medicare Part B, the IPPE and screening EKG services are billable with the appropriate HCPCS G code(s).  The physician or qualified NPP shall bill HCPCS code G0402 for the IPPE performed face -to-face with the patient.   The physician or entity shall bill HCPCS code G0403 for performing the complete screening EKG that includes the tracing, interpretation and report.  The physician or entity that performs the screening EKG tracing only (without interpretation and report) shall bill HCPCS code G0404.  The physician or entity that performs the screening EKG interpretation and report only, (without the EKG tracing) shall bill HCPCS code G0405.  2. HCPCS Codes Used to Bill the AWV  For the first AWV provided on or after January 1, 2011, the health professional shall bill HCPCS G0438 (Annual wellness visit, including PPPS, first visit).  This is a once per beneficiary per lifetime allowable Medicare Part B benefit.   All subsequent AWVs shall be billed with HCPCS G0439 (Annual Wellness Visit, including PPPS, subsequent visit). In the event that a beneficiary selects a new health professional to complete a subsequent AWV, the new health professional will continue to bil l the subsequent AWV with HCPCS G0439.   NOTE:  For an IPPE or AWV performed during the global period of surgery, refer to chapter 12, 30.6.6 of this chapter for reporting instructions.  G. Documentation for the IPPE or AWV   Practitioners eligible to furnish an IPPE or an AWV are required to use the 1995 and 1997 E/M documentation guidelines to document the medical record with the appropriate clinical information. (http://xmarks.com/site/www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp).  All referrals and a written medical plan must be included in this documentation.   H. Reporting a Medically Necessary E/M Service Furnished During the Same Encounter as an IPPE or AWV   When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes 99201 -  99215 may be reported depending on the clinical appropriateness of the circumstances. CPT Modifier - 25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whicheve r applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).   NOTE:   Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be billed for  the medically necessary, separately identifiable, E/M service.   30.6.2 - Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service  (Rev. 1, 10- 01-03)  See Chapter 18 for payment for covered preventive services.  When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a noncovered preventive medicine service (CPT codes 99381- 99397), consider the covered visit to be provided in lieu of a part of the preventive medicine service of equal value to the visit.  A preventive medicine service (CPT codes 99381 -99397) is a noncovered service.  The physician may charge the benefici ary, as a charge for the noncovered remainder of the service, the amount by which the physicians current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit.  Pay for the covered visit ba sed on the lesser of the fee schedule amount or the physicians actual charge for the visit.  The physician is not required to give the beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit.  However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury. There could be covered and noncovered procedures performed during this encounter (e.g., screening x -ray, EKG, lab tests.).  These are considered individually.  Those procedures which are for screening for asymptomatic conditions are considered noncovered a nd, therefore, no payment is made.  Those procedures ordered to diagnose or monitor a symptom, medical condition, or treatment are evaluated for medical necessity and, if covered, are paid.   30.6.3 - Payment for Immunosuppressive Therapy Management  (Rev. 1, 10- 01-03) B3-4820- 4824 Physicians bill for management of immunosuppressive therapy using the office or subsequent hospital visit codes that describe the services furnished.  If the physician who is managing the immunotherapy is also the transplant surgeon, he or she bills these visits with modifier  -24 indicating that the visit during the global period is not related to the original procedure if the physician also performed the transplant surgery and submits documentation that shows that the visit is for immunosuppressive thera py.  30.6.4 - Evaluation and Management (E/M) Services Furnished Incident to Physicians Service by Nonphysician Practitioners  (Rev. 1, 10- 01-03)  When evaluation and management services are furnished incident to a physicians service by a nonphysician practitioner, the physician may bill the CPT code that describes the evaluation and management service furnished.  When evaluation and management services are furnished incident to a physicians service by a nonphysician employee of the physician, not as part of a physician service, the physician bills code 99211 for the service. A physician is not precluded from billing under the incident to provision for services provided by employees whose services cannot be paid for directly under the Medicare program.  Employees of the physician may provide services incident to the physicians service, but the physician alone is permitted to bill Medicare.  Services provided by employees as incident to are covered when they meet all the requirements for incident to and are medically necessary for the individual needs of the patient. 30.6.5 - Physicians in Group Practice  (Rev. 1, 10- 01-03)  Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.  If more than one evaluation and management (face -to-face) service is provided on the same day to the same patient by the same  physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.  Instead of billing separately, the physicia ns should select a level of service representative of the combined visits and submit the appropriate code for that level.  Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group. 30.6.6 - Payment for Evaluation and Management Services Provided During Global Period of Surgery  (Rev. 954, Issued: 05- 19-06, Effective: 06 -01-06, Implementation: 08- 20-06)  A. CPT Modifier  -24 - Unrelated Evaluation and Management Service by Same Physician During Postoperative Period