EM Coding Alert

Question: I know how to code initial preventive physical exams (IPPEs) for most of our Medicare patients. I am wondering how to report IPPEs for patients who have been with Medicare more than a year? What about coding IPPEs for private payers?

Minnesota Subscriber

Answer: Coding “Welcome to Medicare” IPPEs is pretty basic … except when it isn’t. Follow these tips for spot-on IPPEs for all your patients.

Medicare patients: If the IPPE occurs within the first year of the patient’s Medicare enrollment, report G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment). Also, make sure that this is the patient’s first IPPE since enrolling with Medicare, or they aren’t eligible for G0402 services.

If the patient has been enrolled in Medicare for more than 12 months before her first IPPE, however, coding will change. For these encounters, you might report a code such as G0438 (Annual wellness visit; includes a personalized prevention plan of service, initial visit) or G0439 (…  includes a personalized prevention plan of service, subsequent visit) rather than G0402. Check your individual Medicare payer’s policy if you’re unsure how to code for these services. Additionally, you will want to make certain all requirements of the code have been met within the documentation of the service.

Non-Medicare patients: Since the “Welcome …” exam is a Medicare benefit, you must be sure that the patient is a Medicare beneficiary — or has insurance that follows Medicare’s billing rules — before choosing G0402 for an IPPE. If you’re unsure how to code an IPPE for a private payer, check with the payer before filing the claim.

Also: There are services the physician might provide during an IPPE that you could also code separately, depending on the payer’s specific policy. For example, many Medicare payers consider an electrocardiogram (EKG) during an IPPE a separately reportable service. So if your physician performs an IPPE on a Medicare patient whose been enrolled for six months, and also performs an EKG during the visit, you should report G0402 along with one of the following EKG codes:

• 93000, Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
• 93005, … tracing only, without interpretation and report
• 93010, … interpretation and report only.

Best bet: Dig into your payer contracts to see what services are separately reportable during Medicare (and private payer) IPPEs.