(Medicare Claims Processing Manual)

The IPPE includes:   (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 appropriate screening and other preventive services, which are separately covered under Medicare Part B.   Medicare will pay for only one IPPE per beneficiary per lifetime.  The Common Working File (CWF) will edit for this benefit.   The IPPE does not include other preventive services that are currently separately covered and paid 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 nut rition therapy for individuals with diabetes or renal disease, cardiovascular screening blood tests, diabetes screening tests, screening ultrasound for abdominal aortic aneurysms, an electrocardiogram, and additional preventive services covered under Medic are Part B through the Medicare national coverage determination process.)   For the physician/practitioner billing correct coding and payment policy, refer to chapter 12, section 30.6.1.1, of this manual.  80.1 - Healthcare Common Procedure Coding System (HCPCS) Coding for the IPPE  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  The HCPCS codes listed below were developed for the IPPE benefit effective January 1, 2005, for individuals whose initial enrollment is on or after January 1, 2005.  G0344:   Initial preventive physical examination; face -to-face visit, services limited to new beneficiary during the first 6 months of Medicare enrollment   Short Descriptor:  Initial Preventive Exam   G0366:   Electrocardiogram, routine ECG with 12 leads; performed as a component of the initial preventive examination with interpretation and report   Short Descriptor :  EKG for initial prevent exam  G0367:  tracing only, without interpretation and report, performed as a component of the initial preventive examination   Short Descriptor:  EKG tracing for initial prev   G0368:  interpretation and report only, performed as a component of the initial preventive examination  Short Descriptor:   EKG interpret & report preve   The following new HCPCS codes were developed for the IPPE benefit effective January 1, 2009, and replaced codes G0344, G0366, G0367, and G0368 shown above beginning with dates of service on or after January 1, 2009:   G0402:  Initial preventive physical examination; face -to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment   Short Descriptor:  Initial Preventive exam   G0403:  Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report   Short Descriptor:  EKG for initial prevent exam  G0404:  Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination   Short Descriptor:  EKG tracing for initial prev   G0405:  Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination  Short Descriptor:  EKG interpret & report preve   80.2 - A/B MAC) (B) Billing Requirements  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Effective for dates of service on and after January 1, 2005, through December 31, 2008, A/B MACs (B)  shall recognize the HCPCS codes G0344, G0366, G0367, and G0368 shown above in 80.1 for an IPPE.  The type of service (TOS) for each of these codes is as follows:   G0344: TOS = 1 G0366: TOS = 5 G0367: TOS = 5 G0368: TOS = 5  A/B MACs (B)  shall pay physicians or qualified nonphysician practitioners for only one IPPE performed not later than 6 months after the date the individuals first coverage begins under Medicare Part B, but only if that coverage period begins on or after January 1, 2005.  Effective for dates of service on and after January 1, 2009, A/B MACs (B)  shall recognize the HCPCS codes G0402, G0403, G0404, and G0405 shown above in 80.1 for an IPPE.  The TOS for each of these codes is as follows:   G0402:  TOS = 1 G0403:  TOS = 5 G0404:  TOS = 5 G0405:  TOS = 5  Under the MIPPA of 2008, A/B MACs (B)  shall pay physicians or qualified nonphysician practitioners for only one IPPE performed not later than 12 months after the date the individuals first coverage begins under Medicare Part B only if that coverage period begins on or after January 1, 2009.  A/B MACs (B)  shall allow payment for a medically necessary Evaluation and Management (E/M) service at the same visit as the IPPE when it is clinically appropriate.  Physicians and qualified nonphysician practitioners shall use CPT codes 99201- 99215 to report an E/M wi th CPT modifier 25 to indicate that the E/M is a significant, separately identifiable service from the IPPE code reported (G0344 or G0402, whichever applies based on the date the IPPE is performed).  Refer to chapter 12, 30.6.1.1, of this manual for the physician/practitioner billing correct coding and payment policy regarding E/M services.   If the EKG performed as a component of the IPPE is not performed by the primary physician or qualified NPP during the IPPE visit, another physician or entity may perform and/or interpret the EKG.  The referring physician or qualified NPP needs to make sure  that the performing physician or entity bills the appropriate G code for the screening EKG, and not  a CPT code in the 93000 series.  Both the IPPE and the EKG should be billed in order for the beneficiary to receive the complete IPPE service.  Effective f or dates of service on and after January 1, 2009, the screening EKG is optional and is no longer a mandated service of an IPPE if  performed as a result of a referral from an IPPE.   Should the same physician or NPP need to perform an additional medically necessary EKG in the 93000 series on the same day as the IPPE, report the appropriate EKG CPT code(s) with modifier 59, indicating that the EKG is a distinct procedural service.   Physicians or qualified nonphysician practitioners shall bill the A/B MACs (B)  the appropriate HCPCS codes for IPPE.  The HCPCS codes for an IPPE and screening EKG are paid under the Medicare Physician Fee Schedule (MPFS).  See 1.3 of this chapter for waiver of cost sharing requirements of coinsurance, copayment and deductible for furnished preventive services available in Medicare.   80.3 - A/B MAC (A) Billing Requirements  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  A/B MACs (A)  will pay for IPPE or EKG only when the services are submitted on one of the following TOBs: 12X, 13X, 22X, 71X, 73X and 85X.   Type of facility and setting determines the basis of payment:    For the IPPE or the screening EKG tracing only performed on a 12X and 13X TOB, hospital inpatient Part B and hospital outpatient, for hospitals subject to the outpatient prospective payment system (OPPS), under the OPPS.  Hospitals not subject to OPPS shal l be paid under current methodologies.    For services performed on an 85X TOB, Critical Access Hospitals (CAHs), pay on reasonable cost.   For services performed in a skilled nursing facility, TOB 22x, make payment for the technical component of the EKG based on the MPFS.    For inpatient or outpatient services in hospitals in Maryland, make payment according to the Health Services Cost Review Commission.    For services performed on a 12X TOB, Indian Health Services (IHS) hospitals, payment is made based on an all -inclusive ancillary per diem rate.    For services performed on a 13X TOB, IHS hospitals, payment is made based on the all -inclusive rate (AIR).    For services performed on an 85X TOB, IHS CAHs, payment is made based on an all -inclusive facility specific per visit rate.   All CAHs are paid for the technical or facility component of the IPPE itself.  They are also paid for the technical component of the EKG, the tracing only, if the EKG is performed.  Only CAHs paid under the optional method are paid for the professional component of the IPPE itself (in addition to the facility payment) for charges under revenue code 0960.  If the EKG is performed, CAHs paid under the optional method may also be paid for the interpretation of the EKG (in addition to the payment for the tracing) when billed under revenue codes 0985 or 0986.  80.3.1 - Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC) Special Billing Instructions  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  There are Initial Preventive Physical Examination ( IPPE)  instructions that are unique to Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).  Refer to chapter 9, section 70.6 of this manual for a description of these instructions.  80.3.2 - Indian Health Services (IHS) Hospitals Special Billing Instructions  (Rev. 1615, Issued: 10- 17-08, Effective: 01 -01-09, Implementation: 01- 05-09)  For the period January 1, 2005 through December 31, 2008, the designated A/B MAC (A) pays IHS hospitals when G0344 is submitted; this includes the IPPE whether or not the screening EKG is performed at the same time.  The designated A/B MAC (A) will also pa y IHS hospitals for the screening EKG if HCPCS code G0367 is present.  For the professional component of the EKG, the designated A/B MAC (B) shall pay the billing physician or other practitioner the established amount.  Effective January 1, 2009 the following new HCPCS codes have been developed for the IPPE benefit and replace the codes in the paragraph above:  G0402 for the IPPE itself, and G0404 for the technical component (tracing only) of the EKG.  80.3.3 - Outpatient Prospective Payment System (OPPS) Hospital Billing (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  Hospitals subject to OPPS (TOBs 12X and 13X) must use modifier - 25 when billing the IPPE G0344 along with the technical component of the EKG, G0367, on the same claim.  The same is true when billing IPPE code G0402 along with the technical component of the screening EKG, code G0404.  This is due to an OPPS Outpatient Code Editor (OCE) which contains an edit that requires a modifier - 25 on any evaluation and management (E/M) HCPCS code if there is also a status S or T HCPCS procedure code on the claim.   80.4 - Coinsurance and Deductible  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.