Practice Management Alert

Question: I’ve recently taken on some coding/billing duties while our lead coder is on leave. I have a claim here for a “Welcome to Medicare” initial preventive physical examination (IPPE) for a new 67-year-old patient. How should I report this encounter?

Alaska Subscriber

Answer: In most cases, you should not use a standard E/M office visit code for a “Welcome to Medicare” exam (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient … ). The code you choose will depend mostly on the patient’s Medicare enrollment status. 

Typically, you should instead report G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment). You should only report G0402 when the patient’s IPPE occurs less than 12 months after her date of Medicare enrollment. Also, patients are only eligible for G0402 if the patient has not had an IPPE since enrolling with Medicare.

Caveat: If the patient has been enrolled in Medicare for more than 12 months, you cannot report the IPPE with G0402. For these patients, you might report a code such as G0438 (Annual wellness visit; includes a personalized prevention plan of service [PPS], initial visit) or G0439 (Annual wellness visit; includes a personalized prevention plan of service [PPS], subsequent visit) rather than G0402.