Code initial Medicare well-exams with G0344 A new Medicare benefit means your FP will finally get paid for some preventive medicine services - provided you know these rules. Report Medicare PE Services 2 Ways Starting Jan. 1, you'll have to code physical exams (PE) to Medicare recipients using two methods. "Coders are really going to have to pay attention when billing Medicare for preventive medicine services," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "The new Welcome to Medicare (WMT) benefit introduces a brand new coding concept." Target Risk Factors With IPPE The age-appropriate exam that your FP performs in a PE focuses on different areas than an IPPE targets. Therefore, CMS valued the new service at a level equal to 99203, rather than 99387 or 99397. Use IPPE-Specific ECG Codes Instead of 93000 The IPPE also includes a separately billable electrocardiogram (ECG). "But you won't use the normal 93000 (Electrocardiogram, routine ECG with at least 12 leads ...) series codes that you normally associate with an ECG," warns Callaway. Diagnosis: Because this exam is a preventive visit, you should link ICD-9 code V70.0 (Routine general medical examination at a health care facility) to G0344 and G0366-G0368, says Callaway. "Remember this is a screening ECG, not a complaint-oriented one." Assign Appropriate Level Sick Visit If a patient also presents with a complaint that requires treatment, you may report any level office visit code appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of another service or procedure), in addition to G0344. "Medicare wanted to restrict same-day problem-related services to a level two office visit," says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan. Gain PE Payment - But Is 99203 Enough Reimbursement for the new benefit is a mixed bag.
Old method: You previously should have coded Medicare PEs with 99387 (Initial comprehensive preventive medicine evaluation and management of an individual ... 65 years and over) or 99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... 65 years and over). "Of course, you wouldn't bill Medicare for the non-covered service," says Callaway. You'd instead charge 99387 or 99397 to the patient.
If the family physician (FP) performed a well woman exam, you'd also code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory). "Medicare would reimburse these services," adds Callaway.
New way: When a patient is brand new to Medicare, you may code the first PE - dubbed the IPPE (initial preventive physical exam) - with G0344 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first six months of Medicare enrollment).
Medicare intends the IPPE "to target selected modifiable risk factors and secondary prevention opportunities" that evidence shows "improve the health and welfare of the beneficiary," CMS states in 2005 Medicare Fee Schedule final rule.
In addition, when compared to 99397, the new benefit focuses less on a comprehensive physical examination, according to the final rule.
A few items that CMS' final rule says physicians should perform with an IPPE include:
looking for "modifiable risk factors for disease," or conditions where early detection could make a huge difference;
seeking information on a patient's diet, alcohol, tobacco and drug use and physical activities; and
looking for risk factors for depression.
Instead: You should code the diagnostic procedure with G0366 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report, performed as a component of the initial preventive physical examination), provided your FP performs the service in the office.
If your FP doesn't have an ECG machine, bill one of two other new G codes, depending on what portion of the diagnostic procedure your physician performs. Choose from:
Watch out: CMS hasn't yet issued billing instructions for the IPPE and IPPE-related ECG. Therefore, even though V70.0 seems the most probable ICD-9 code, the information is subject to change.
But after many physicians complained that this would be unfair, CMS backed off on this position. "So [in addition to the WTM], you can bill at whatever level E/M service" your FP performed and documented," says Moore.
Good news: Medicare will pay for G0344. "CMS will reimburse the IPPE at about the same level as a 30-minute office visit," states the American Academy of Family Physician's (AAFP) announcement regarding the new benefit.
The AAFP, however, expresses concern that Medicare may not pay enough for the visits. "... initial visits - particularly for an older person who may have multiple health conditions - often require more time" than a level-three new patient office visit (99203, Office or other outpatient service for the evaluation and management of a new patient ...) typically takes, according to the AAFP's article "Welcome to Medicare benefits incorporate AAFP suggestions."
Bottom line: Code G0344 contains approximately the same number of relative value units (RVUs) - 2.57 RVUs - as 99203 (2.56 RVUs) and reimburses at a national rate of $97.40.
Editor's note: For ways to ethically optimize your IPPE pay, see "Capture IPPE Dollars With These Strategies" on this page. For additional information regarding the AAFP's opinion on Medicare's WTM benefit, visit www.aafp.org/x30564.xml. You may download Medicare's physician fee schedule from the CMS Web site at www.cms.hhs.gov/regulations/pfs/2005/1429fc.asp.