Internal Medicine Coding Alert

Published on Mon May 14, 2012 PDF

Here's your checklist of what providers must document.

"The various components of the IPPE must be provided and documented in a beneficiary's medical record" before you can submit G0402, says Kathleen Kersell with the Center for Medicare Provider Billing Group. An IPPE must include (and document):

• Review of the patient's medical and social history
• Review of potential risk factors for depression and other mood disorders
• Review of functional ability and level of safety
• Measurement of height, weight, body mass index, blood pressure, visual acuity screen, and other factors deemed appropriate based on the patient's medical and social history and current clinical standards
• Discussion of end-of-life planning, upon agreement of the individual
• Education, counseling, and referrals based on results of review and evaluation services performed during the visit. Education should include a brief written plan such as a checklist and, if appropriate, education, counseling, and referral for obtaining an electrocardiogram (EKG or ECG).