Primary Care Coding Alert

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).