Welcome-to-Medicare Exam

by Corrie Alvarez, CPC, CPC-I, CEDC

In 2003, Congress passed the Medicare Prescription Drug, Improvement and Modernization Act (MMA), which provided newly eligible Medicare recipients to receive a one-time initial preventive physical examination (IPPE).

CPB : Online Medical Billing Course

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), extended the timeline for completion of this physical examination from six months to one year from the patient’s initial enrollment date.

On January 1, 2009, coverage for the Initial Preventive Physical Examination (IPPE) was expanded to include measurement of an individual’s body mass index and end-of-life planning.

Medicare recipients are eligible to receive a “Welcome to Medicare” physical examination. This is a one-time benefit that must be performed within 12 months from the time the patient becomes eligible for Part B benefits. The out-of-pocket expense for the patient is 20% of the Medicare-approved amount, and the annual Part B deductible is waived for this examination.

The goals of the program are to promote good health as well as disease detection. The following components must be provided on the examination:

  1. Review and documentation of the patient’s medical and social history
  2. Review and documentation of patient’s potential risk factors for depression and/or other mood disorders.
  3. Review and documentation of patient’s functional ability and level of safety
  4. Physical examination, including measurement of body mass index
  5. End-of-life planning
  6. Education, counseling and referral (if necessary) based on the five items above
  7. Education, counseling and referral for other preventive services

The proper HCPCS code for the IPPE visit is G0402. There is no specific diagnosis code requirement for this examination, but a diagnosis is required on all claims submitted.

The screening electrocardiogram is no longer a mandatory part of the IPPE, but it is permitted as a one-time screening service as a result of a referral arising out of the IPPE.

The code for billing the EKG would be G0403 (G0404 tracing only, G0405 interpret and report only).

The program does not pay for additional testing covered under the patient’s Part B program. The additional testing, if warranted, would be billed separately and covered, based on the medical necessity guidelines.

So, what do you do if there are positive findings on the IPPE examination, and the patient needs further testing not covered under the IPPE exam? You can bill for a separate examination, using the proper evaluation and management code, based on the history, examination and medical decision making documented for the service. You could order the necessary testing, limited by medical necessity guidelines, using the proper diagnosis for the additional services ordered. For example, if you note on examination that the patient has a chronic cough, you would document the proper history and respiratory examination. If medically necessary, you would order a chest x-ray and bill Medicare for the additional examination and chest x-ray with a diagnosis of 786.2.

The Initial Preventive Physical Examination helps to improve the education and health of your patient, and it provides as a good way to maximize revenue.


by Corrie Alvarex, CPC, CPC-I, CEDC

Latest posts by admin aapc (see all)

One Response to “Welcome-to-Medicare Exam”

  1. Shawna Frost says:

    I started my own small business as a family nurse practitioner completing advance directives with clients and their home. I submit billing to CMS for payment. I was wondering if I could include welcome to Medicare visit to my home based business? I could receive referrals from primary care providers to complete the welcome to Medicare visit. Do you think this would work? Shawna Frost

Leave a Reply

Your email address will not be published. Required fields are marked *