Final Rule Raises “Welcome to Medicare” Benefit Value
IPPE changes reflect an increased focus on primary care, health promotion, and disease prevention.
By Torrey Kim, MA, CPC
Among many noteworthy items contained within the 2010 Medicare Physician Fee Schedule (MPFS) Final Rule is an increase in value for the so-called “Welcome to Medicare” benefit—known formally as the Initial Preventative Physical Examination (IPPE).
Section 611 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) established the IPPE benefit. The benefit subsequently was revised by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), for services beginning Jan. 1, 2009.
Under Part B, Medicare will cover an initial preventive physical examination for a new beneficiary (one IPPE per beneficiary, per lifetime). Initially, the eligibility period for receiving an IPPE was within six months of the beneficiary’s Part B enrollment date. MIPPA extended this eligibility period to within 12 months of an individual’s enrollment in Medicare Part B.
Tip: When scheduling a beneficiary’s IPPE, practices should check the patients’ eligibility with Medicare to make sure he or she doesn’t have Medicare managed care. Check the patients’ Medicare cards, as well, to confirm his or her eligibility dates, and to make sure he or she is within the IPPE eligibility period. You should also double-check with the patient to confirm he or she has not already had an IPPE with another physician.
The service may be performed by a doctor of medicine or osteopathy, or by a qualified non-physician practitioner (NPP) (i.e., nurse practitioner (NP), physician assistant (PA), and clinical nurse specialist (CNS)). The IPPE encompasses a broad array of components and focuses on primary care, health promotion, and disease prevention, according to the Centers for Medicare & Medicaid Services (CMS). As defined in chapter 12, section 18.104.22.168 of the Medicare Claims Processing Manual, the IPPE includes:
- A review of the individual’s medical and social history with attention to modifiable risk factors for disease detection.
- A review of the individual’s potential (risk factors) for depression or other mood disorders.
- A review of the individual’s functional ability and safety level.
- A physical examination to include measurement of the individual’s height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate by the examining physician or qualified NPP.
- Education, counseling, and referral, as deemed appropriate based on the results of the review and evaluation services described in the previous elements.
- Education, counseling, and referral including a brief written plan (for instance, a checklist or alternative) provided to the individual for obtaining the appropriate screening and other preventive services.
Under MIPPA, the IPPE also must include measurement of the beneficiary’s body mass index (BMI), and (upon an individual’s consent) end-of-life planning.
The appropriate code to report an IPPE is G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment. The Medicare deductible does not apply to IPPEs (code G0402) performed on or after Jan. 1, 2009. Coinsurance, however, does apply.
Prior to MIPPA, screening electrocardiogram (EKG) was a mandatory component of an IPPE. Since MIPPA (beginning Jan. 1, 2009), screening EKG is optional and is permitted as a one-time screening service as a result of a referral arising out of the IPPE. Screening EKG, if performed, is reported separately from G0402 using, as appropriate:
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
Note that G0403 describes the global EKG (including tracing with interpretation and report), while G0404 and G0405 describe the tracing only, and interpretation and report only, respectively. Note also that the waived deductible for the IPPE does not apply to the screening EKG service, irrespective of the codes used or service date.
This instruction, along with additional, complete content and coding guidelines for the IPPE, are outlined in the CMS Transmittal 1615, Change Request 6223, dated Oct. 17, 2008 (www.cms.hhs.gov/transmittals/downloads/R1615CP.pdf).
For 2010, the reporting requirements for the IPPE do not change; however, code G0402 is revalued. According to the MPFS Final Rule, upon review, CMS felt “the services, in the context of work and intensity, contained in HCPCS code G0402 are most equivalent to those services contained in CPT code 99204 Evaluation and management new patient, office or other outpatient visit.” As such, CMS has increased the work relative value units (RVUs) for HCPCS Level II code G0402 to 2.30—up from 1.34 in 2009—effective for services furnished beginning on Jan. 1. At current rates, this will increase provider payment for the service by roughly $30.
Resource tip: See 42 CFR Parts 410, 411, 414 et al. Medicare Program; Payment Policies, Under the Physician Fee Schedule and Other Revisions to Part B for 2010; Final Rule (2010 Medicare Physician Fee Schedule Final Rule) in the Nov. 25, 2009 Federal Register at: http://edocket.access.gpo.gov/2009/pdf/E9-26502.pdf. The information on IPPE begins on page 61766 (page 30 of the viewable .pdf file).