The Affordable Care Act of 2010 amended the definition of “preventive services” available in Medicare and included two additional preventive physical examination services: the initial preventive physical examination (IPPE) and the annual wellness visit (AWV). As with any new benefit, though, the IPPE and AWV have been sources of confusion for many health providers and support staff.

If you fall among the ranks of the confused, you may be interested to know that the Centers for Medicare & Medicaid Services (CMS) recently posted on its website six new frequently asked questions (FAQs) regarding the IPPE. Although this information is not new, it serves to clear up common misperceptions providers have about this Medicare benefit.

Here are the IPPE questions and answers posted June 17:

Q: Are clinical laboratory tests part of the Initial Preventive Physical Examination (IPPE)?

A: No, the IPPE does not include any clinical laboratory tests, but the provider may want to make referrals for such tests as part of the IPPE.

Q: Is there a deductible or coinsurance/copayment for the Initial Preventive Physical Examination (IPPE)?

A: Coverage for the IPPE is provided as a Medicare Part B benefit. For dates of service prior to January 1, 2011, the annual Medicare Part B deductible is waived for the IPPE (HCPCS code G0402), but the coinsurance or copayment still applies. The deductible still applies to the optional screening EKG (HCPCS codes G0403, G0404, or G0405). For dates of service on or after January 1, 2011, both the Medicare Part B deductible and the coinsurance or copayment are waived for the IPPE only. Neither is waived for the screening EKG.

Q: If a beneficiary enrolled in Medicare in 2010, can he or she have the Initial Preventive Physical Examination (IPPE) in 2011 if it was not performed in 2010?

A: A beneficiary, who has not yet had an IPPE and whose initial enrollment in Medicare Part B began in 2010, will be able to have an IPPE in 2011, as long as it is done within 12 months of the beneficiary’s initial Medicare Part B enrollment effective date.

Q: Is the Initial Preventive Physical Examination (IPPE) the same as a beneficiary’s yearly physical?

A: No, this exam is a preventive physical exam and not a “routine physical checkup” that some seniors may receive every year or two from their physician or other qualified non-physician practitioner. For a newly enrolled beneficiary, the IPPE is an introduction to Medicare and covered benefits. Medicare does not provide coverage for routine physical exams.

Q: Can a separate E/M service be billed at the same visit as the IPPE?

A: Medicare payment can be made for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201-99215) billed at the same visit as the IPPE when billed with modifier 25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.

Q: Who can perform the Initial Preventive Physical Examination (IPPE)?

A: The IPPE must be furnished by either a physician (a doctor of medicine or osteopathy) or a qualified non-physician practitioner (a physician assistant, nurse practitioner, or clinical nurse specialist).

You’ll find other FAQs regarding all things Medicare on the CMS website.

Also note that the 2011 Medicare Physician Fee Schedule (MPFS) published a table of preventive services that was just recently added to Chapter 18 (Preventive and Screening Services) of the Medicare Claims Processing Manual, Pub. 100-04. Change Request (CR) 7423 is being implemented via the Recurring Update Notification form as CMS will update the preventive table as new services become available.


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