IPPE or AWE? Navigate Yearly Medicare Visits

IPPE or AWE? Navigate Yearly Medicare Visits

Reimbursement depends on clearly determining why the patients coming to your office.

The complementary yearly Medicare visits are tricky to get paid correctly because they require specific documented information to qualify for coverage.

Many believe the Annual Wellness Visit (AWV) is simply a yearly physical, but that is not the case. When a Medicare patient calls for an “annual visit,” it’s important to determine prior to the visit what exactly the patient is coming in for. If you wait until after the clinician sees the patient to make the determination, you may end up with a patient getting an unexpected medical bill for services they didn’t want or a clinician not getting paid the proper fee for services furnished.

Let’s review the different visits a patient may request to see how coding and reimbursement plays out for each scenario.

Possibility No. 1 The Yearly Physical

Medicare does not reimburse for preventive medicine services (CPT® 99381-99397). For these services, the patient should be asked to sign an Advance Beneficiary Notice (ABN), to acknowledge responsibility for the cost of the service, outside of any secondary insurance coverage. Append to the evaluation and management (E/M) code modifier GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit to indicate a signed ABN is on file.

A patient calling to schedule a visit that is 100 percent covered by Medicare is not requesting a yearly physical.

Possibility No. 2 The Initial Preventive Physical Examination (IPPE)

The IPPE, or “Welcome to Medicare” preventive visit, is a one-time visit provided to Medicare Part B patients within their first 12 months of Medicare enrollment. To determine if this is what a patient is requesting:

Step 1: Determine whether the patient is within the first 12 months of Medicare enrollment. If yes, then the IPPE visit is the most appropriate. If no, then the IPPE visit is not covered and a different service should be performed.

Step 2: Make sure the appropriate functions are completed at the visit. The IPPE has specific components the provider is expected to address and document, as shown in Table 1. These elements must be provided to the patient before submitting a claim for the IPPE service.

Step 3: Conduct the patient visit. The IPPE can be performed by a physician or other qualified non-physician practitioner. There is no copay or deductible for the IPPE visit; however, if other services are performed at the same visit, a copay or deductible may apply to those services.

Step 4: Submit the claim. When all components of the IPPE are provided, the HCPCS Level II code for the IPPE and the appropriate HCPCS Level II code for the electrocardiogram (ECG):

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

Medicare does not require a specific ICD-10-CM diagnosis code for the IPPE, but a diagnosis code consistent with the patient’s exam must be used. Other medically necessary services performed on the same date of service may be billed with the addition of the appropriate modifier.

Note: Never bill a depression screening (G0444 Annual depression screening, 15 minutes) with the IPPE visit because that is part of the Acquire Beneficiary Information component.

Table 1: Components of the IPPE

Component Action
Acquire Beneficiary Information Review the patient’s medical and social history

Review the patient’s potential risk factors for depression and other mood disorders

Review the patient’s functional ability and level of safety

Begin Examination and Discussion Exam

End-of-life planning, on agreement of the patient

Counsel Beneficiary Educate, counsel, and refer based on the previous five components

Educate, counsel, and refer for other preventive services

Include once-in-a-lifetime screening electrocardiogram (ECG)

 

Possibility No. 3: The Initial AWV

A patient requesting an annual visit may be eligible for an initial AWV, which is a one-time-only benefit for Medicare Part B beneficiaries who are not within the first 12 months of their coverage effective date.

Step 1: Determine if the patient is eligible for an initial AWV involves by establishing whether or not the patient is outside of the first 12 months of Medicare Part B enrollment, and whether or not the patient has received an IPPE or AWV within the last 12 months. To qualify for an initial AWV, it must be more than 12 months since the patient’s Medicare coverage effective date, and the patient cannot have received a prior AWV in the past 12 months.

Step 2: Make sure the appropriate functions are completed at the visit. Like the IPPE visit, the initial AWV includes specific components that must be addressed and documented, as shown in Table 2.

Although the initial AWV has similar components to the IPPE visit, there are many differences. One major difference is the HRA. The Centers for Disease Control and Prevention (CDC) developed a framework publication detailing the HRA. It’s also important to understand that, like the IPPE, the initial AWV is not a physical. The assessment of the patient only includes routine measurements, not an assessment of the patient’s overall wellbeing.

Step 3: Conduct the patient visit. There is no copay or deductible for the IPPE visit; however, if other services will be performed at the same visit, a copay or deductible may apply to those services.

Step 4: Submit the claim. After all components of the AWV have been provided, code and submit the claim with the appropriate HCPCS Level II code:

G0438     Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit

Medicare does not require a specific ICD-10-CM diagnosis code, but a diagnosis code must be used. If any other medically necessary services are performed on the same date of service, they may be billed with an appropriate modifier. The initial AWV does not include labs or other tests.

Note: Never bill depression screening (G0444) with the initial AWV visit because it’s part of the Acquire Beneficiary Information component.

Table 2: Components of the Initial AWV

Component Action
Acquire Beneficiary Information Administer a health risk assessment (HRA).

Establish a list of current providers and suppliers.

Establish the patient’s medical and family history.

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

Review the patient’s functional ability and level of safety.

Begin Assessment Assess – obtaining height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure.

Detect cognitive impairment the patient may have.

Counsel Beneficiary Establish a written screening schedule for the patient, such as a checklist for the next five to 10 years, as appropriate.

Establish a list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended or underway for the patient.

Furnish personalized health advice to the patient and appropriate referrals to health education or preventive counseling services or programs.

Furnish, at the discretion of the patient, advance care planning services.

 

Possibility No. 4: The Yearly AWV

A Medicare Part B patient may receive a yearly AWV to develop or update their Personalized Prevention Help Plan with their primary care physician. This AWV is offered once every 12 months – at least 11 full months must have passed since the last AWV or the IPPE.

Step 1: Determine if the patient is eligible. If it has been 11 full months since the patient’s last AWV or the IPPE, and the patient is not eligible for the IPPE or the initial AWV, then the patient is eligible for the yearly AWV.

Step 2: Ensure the appropriate components of the visit are completed. Most of the components of the initial AWV are in the yearly AWV; however, now the provider is updating the information rather than establishing it. All components must be addressed and documented, as shown in Table 3.

Table 3: Components of the Yearly AWV

Component Action
Acquire Beneficiary Information Update HRA

Update the list of current providers and suppliers.

Update the patient’s medical/family history.

Begin Assessment Assess – Weight (or waist circumference, if appropriate) and blood pressure.

Detect cognitive impairment the patient may have.

Counsel Beneficiary Update the written screening schedule for the patient.

Update the list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended or underway for the patient.

Furnish personalized health advice to the patient and appropriate referrals to health education or preventive counseling services or programs.

Furnish, at the discretion of the patient, advance care planning services.

 

Step 3: Conduct the patient visit. There is no copay or deductible for the IPPE visit; however, if other services will be performed at the same visit, a copay or deductible may apply to those services. The AWV does not include labs or other tests.

Step 4: Submit the claim. When all the components have been provided to the patient, code and submit the claim. The appropriate HCPCS Level II code is:

G0439     Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit.

Medicare does not require a specific ICD-10-CM diagnosis code, but a diagnosis code must be used. If any other medically necessary services are performed on the same date of service, they may be billed with the addition of the appropriate modifier.

Note: Unlike the IPPE or initial AWV, a depression screening (G0444) can be billed with the yearly AWV visit since it is not part of the Acquire Beneficiary Information component – there is no modifier required.

A few key takeaways that are important to remember:

  • The IPPE, the initial AWV, and subsequent yearly AWVs are not preventive physical exams.
  • The depression screening (G0444) is included in the IPPE and the initial AWV, but not in subsequent yearly AWVs.
  • There is no copay or deductible for the IPPE or either of the AWVs, but there may be a copay and/or deductible for other services rendered on the same date of service.
  • All components must be met and documented before the IPPE, the initial AWV, or a subsequent yearly AWV can be billed.

Lessons Learned

This is a lot of information to digest, but imagine if the clinician had to determine eligibility and then address and document the correct components while in the room with the patient. That would be an impossible scenario.

For additional information regarding the IPPE, AWVs, and other Medicare preventive services, visit the MLN Education Tool.


Amanda Turner, CPC, CPB, CPMA, CRC, is the manager, appeals operations at Zelis Healthcare. Her experience includes managing audits and provider education. Turner holds a Bachelor of Arts in Professional Writing from Penn State University and is studying at Temple University for a Master of Business Administration in Innovation Management. She is a member of the Blue Bell, Pa., local chapter.

Resources

“The ABCs of the Annual Wellness Visit (AWV),”
www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdf

“The ABCs of the Initial Preventive Physical Examination (IPPE),”
www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf

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