(Medicare Claims Processing Manual)

30.6.1 - Selection of Level of Evaluation and Management Service  (Rev .11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  A.  General Rules   Advise physicians to generally use CPT codes (level 1 of HCPCS) to code physician services, including evaluation and management (E/M) services.  Medicare has created Medicare- specific codes that must be used to report prolonged E/M services and E/M visit c omplexity add- on services.   Medicare will pay for E/M services for specific, non -physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS), and certified nurse midwife (CNM)), whose Medicare benefit permits them to bill these services.  A physician assis tant (PA) may also provide a physician service; however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non -physician practitioners.  The service provided must be medically necessary, and the s ervice must be within the scope of practice for a non- physician practitioner in the State in which he/she practices. Do not pay for CPT evaluation and management codes billed by physical therapists in independent practice or by occupational therapists in i ndependent practice.   The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.   B.  Selection of Level of Evaluation and Management Service   As of January 1, 2023, for most E/M visit families, practitioners will select visit level based on the level of medical decision making (MDM) or the amount of time spent by the physician or non-physician practitioner. For some types of visits (such as emer gency department visits and critical care), in accordance with their CPT codes, practitioners do not have this choice and will use only MDM or only time to bill. The CPT E/M Guidelines for MDM apply. For all E/M visits, history and physical exam must be pe rformed in accordance with code descriptors, but history and exam no longer impact visit level selection. When practitioner time is used to select visit level, the full time must be completed; the general CPT rule regarding the midpoint for certain timed s ervices does not apply.  Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of an E/M visit code.  It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service  is warranted.  The volume of documentation should not be the primary influence upon which a specific level of service is billed.  Documentation should support the level of service reported.     Any physician or non- physician practitioner (NPP) authorized to bill Medicare services will be paid by the Medicare Administrative Contractor (MAC) at the appropriate physician fee schedule amount based on the rendering national provider identifier (NPI) number.  "Incident to" Medicare Part B payment policy is applicable for office visits when the requirements for "incident to" are met (refer to sections 60.1, 60.2, and 60.3, chapter 15 in IOM 100-02).  SPLIT/SHARED E/M SERVICE   See section 30.6.18 for rules regarding billing of E/M visits that are split (or shared).   30.6.1.1 - Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)  (Rev. 3096, Issued: 10- 17-14, Effective: 01 -27-14, Implementation: 11- 18-14)  A. Definitions   1. Initial Preventive Physical Examination (IPPE)   The initial preventive physical examination (IPPE), or Welcome to Medicare Preventive Visit is a preventive visit authorized by sections 1861(s)(2)(w) and 1861(ww) of the Social Security Act (and implementing regulations at 42 CFR 410.16, 411.15(a)(1), a nd 411.15(k)(11)).   As described in the implementing regulations, the IPPE includes the following:   (1) review of the individuals medical and social history with attention to modifiable risk factors for disease detection,   (2) review of the individuals potential (risk factors) for depression or other mood disorders,   (3) review of the individuals functional ability and level of safety,   (4) an examination to include measurement of the individuals height, weight, body mass index, blood pressure, a visual acuity screen, and other factors as deemed appropriate, based on the beneficiarys medical and social history,  (5) end-of-life planning, upon agreement of the individual,   (6) education, counseling, and referral, as deemed appropriate, based on the results of the review and evaluation services described in the previous 5 elements, and   (7) education, counseling, and referral including a brief written plan (e.g., a checklist or alternative) provided to the individual for obtaining the appropriate screening and other preventive services, which are separately covered under Medicare Part B ( that is, pneumococcal, influenza and hepatitis B vaccines and their administration, screening mammography, screening pap smear and screening pelvic examinations, prostate cancer screening tests, colorectal cancer screening tests, diabetes outpatient self-management training services, bone mass measurements, glaucoma screening, medical nutrition therapy for individuals with diabetes or renal disease, cardiovascular screening blood tests, diabetes screening tests, screening ultrasound for abdominal aortic ane urysms, an electrocardiogram, and additional preventive services covered under Medicare Part B through the Medicare national coverage determinations process).   2. Annual Wellness Visit (AWV)   Effective January 1, 2011, Sections 1861(s)(2)(FF) and 1861(hhh) of the Social Security Act and implementing regulations at 42 CFR 410.15, authorize an AWV providing personalized prevention plan services (PPPS).  The AWV is a preventive visit available to eligible beneficiaries, and identified by HCPCS codes G0438 (Annual wellness visit, including PPPS, first visit) and G0439 (Annual wellness visit, including PPPS, subsequent visit).  Information, including definitions of relevant terms and coverage require ments for the AWV are included in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, section 280.5.   The first AWV providing PPPS (HCPCS G0438) is a one time allowed Medicare benefit and includes the following elements furnished to an eligible beneficiary by a health professional:    Review (and administration if needed) of a health risk assessment,    Establishment of the individuals medical/family history,    Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual,   Measurement of the individuals height, weight, body mass index (or waist circumference, if appropriate), blood pressure (BP), and other routine measurements as deemed appropriate, based on the individuals medical and family history,    Detection of any cognitive impairment that the individual may have,    Review of an individuals potential risk factors for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national professional medical organizations,    Review of the individuals functional ability and level of safety, based on direct observation of the individual, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available sc reening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations,    Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and Advisory Committee of Immunizations Practices (ACIP), and the individuals health risk assessment, health status, screening history, and age -appropriate preventive services covered by Medicare,    Establishment of a list of risk factors and conditions of which primary, secondary, or tertiary interventions are recommended or underway for the individual, including any mental health conditions or any such risk factors or conditions that have been ident ified through an IPPE, and a list of treatment options and their associated risks and benefits,    Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self -management or community- based lifestyl e interventions to reduce health risks and promote self -management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition, and,   Any other element(s) determined appropriate by the Secretary through the national coverage determinations process.   Subsequent AWVs providing PPPS (HCPCS G0439) include the following key elements furnished to an eligible beneficiary by a health professional:    Review (and administration, if needed) of an updated health risk assessment,   Update of the individuals medical/family history,    Update to the list of current providers and suppliers that are regularly involved in providing medical care to the individual as that list was developed for the first AWV providing PPPS, or the previous subsequent AWV providing PPPS,    Measurement of an individuals weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on the individuals medical and family history,   Detection of any cognitive impairment that the individual may have,    Update to the individuals written screening schedule as developed at the first AWV providing PPPS,    Update to the individuals list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, as that list was developed at the first AWV providing PPPS, or the previous subsequent AWV providing PPPS,    Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs, and,    Any other element determined appropriate by the Secretary through the national coverage determinations process.   See chapter 18 of this manual for additional information regarding preventive services that are separately covered under Medicare Part B.   B. Who May Perform an IPPE or AWV   The A/B MAC (B) pays the appropriate physician fee schedule amount based on the rendering National Provider Identification (NPI) number.   The IPPE may be performed by:    a doctor of medicine or osteopathy as defined in Section 1861(r) (1) of the Social Security Act, or    a qualified nonphysician practitioner (nurse practitioner, physician assistant or clinical nurse specialist).   The AWV may be performed by a health professional, which is defined as:    a doctor of medicine or osteopathy as defined in Section 1861(r)(1) of the Social Security Act,    a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Social Security Act), or    a medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician (doctor of medicine or osteopathy).   C. Eligibility   1. IPPE   Medicare pays for one IPPE per beneficiary per lifetime for beneficiaries within the first 12 months of the effective date of the beneficiarys first Part B coverage period.   2. AWV   Medicare pays for an AWV for a beneficiary who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and who has not received either an IPPE or an AWV providing PPPS within the past 12 months.  Medicare pa ys for only one first AWV (HCPCS G0438), per beneficiary per lifetime.  All subsequent AWVs must be billed using HCPCS G0439.  D. Deductible and Coinsurance   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