Primary Care Coding Alert

Question: Our office saw a patient that is a Medicare beneficiary. According to the provider’s documentation for the visit, they performed an exam and history, which are parts of an initial preventive physical exam (IPPE), but also addressed a specific problem. I submitted a claim with codes indicating two new patient encounters: One for the IPPE visit and one for the problem, but the claim was denied. How should I report this visit?

Connecticut Subscriber

Answer: According to the Centers for Medicare & Medicaid Services (CMS), you can bill G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment) for an IPPE.

However, the agency recognizes that patients wanting to address a problem while at a preventive services visit is a common occurrence, and they recommend reporting the visit with an additional evaluation and management (E/M) code and appending a modifier.

CMS says: “When you provide an IPPE and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202-99205, 99211-99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.”

Remember than an IPPE is offered only once in a Medicare beneficiary’s lifetime; it’s considered a “Welcome to Medicare” service. If your patient has already had an IPPE, you may need to bill an annual wellness visit (AWV) instead or use a code that shows the patient is a new patient but is seeking an initial office visit that is not part of what Medicare covers regarding preventive services. In such a situation, the same guidance for coding an additional significant, separately identifiable, and medically necessary E/M service applies.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC