Primary Care Coding Alert

Start with G0402 and confirm details from there.

The initial preventive physical exam (IPPE) is an important service for every family physician's office, so be sure you're coding correctly. Learn the criteria IPPE visits must meet and when to use G0402, straight from a recent CMS National Provider Call.

Understand the IPPE Basics

"The IPPE is a one-time visit and is covered for beneficiaries within the first 12 months of Medicare Part B enrollment," says Jamie Hermansen, a health insurance specialist with CMS's Office of Clinical Standards and Quality/Coverage and Analysis Group. "The IPPE is covered by Medicare Part B."

A variety of professionals can furnish the IPPE, including:

• Physician
• Physician assistant
• Nurse practitioner
• Clinical nurse specialist.

Important: The IPPE is a dedicated preventive visit, not an exam addressing specific problems.

"The IPPE is not a head-to-toe physical examination," points out Stephanie Frilling with the Division of Practitioner Services for the Hospital and Ambulatory Policy Group (HAPG). "While there is some overlap, the focus of the IPPE is to furnish education, counseling, and prevention services appropriate for the individual and available in Medicare."

Choose the Correct Codes

A single code applies to the IPPE itself: G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment).

Include any appropriate diagnosis to help justify the visit.

"Although a diagnosis code must be reported on the claim, there are no specific ICD-9 diagnosis codes that are required for the IPPE," says Kathleen Kersell with the Center for Medicare Provider Billing Group.

Example: Appropriate IPPE diagnosis codes could include V70.0 (Routine general medical examination at a health care facility), V70.3 (Other general medical examination for administrative purposes), or V70.9 (Unspecified general medical examination).

"Any other valid, appropriate diagnosis code could be considered acceptable," Kersell adds. "You can also contact your Medicare contractor for any assistance with what type of diagnosis codes you want to have on the claim."

Report Other Services as Appropriate

The beneficiary may have an optional screening electrocardiogram (ECG) in conjunction with the IPPE. To report that service, you will use one of the following codes, depending on what part of the ECG your office provides:

• G0403 -- Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report
• G0404 -- Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination
• G0405 -- Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination.

The IPPE does not include other preventive services, screenings, or lab tests currently covered and paid under section 1861 of the Social Security Act that the physician furnishes during the IPPE visit. For instance, if you provide prostate cancer screening or a screening Pap test and pelvic exam, those are separately reportable. Medicare will pay for them along with the IPPE, assuming the beneficiary meets the coverage requirements relevant to the particular preventive services in question. You do not need to append any modifier to the codes for these services when furnished during the IPPE.

"We believe preventive services furnished in the same visit as the IPPE to be both appropriate and convenient to the beneficiary," Frilling says.

If the physician provides a separate, medically necessary E/M service during the same encounter as the IPPE, append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code. Choose the E/M code from 99201-99215 (Office visit …).

Note: Medicare also allows physicians to bill non-covered preventive services with an IPPE visit. Ask the patient to sign an Advance Beneficiary Notice (ABN) to acknowledge her responsibility in paying for any non-covered services.

Don't Look at IPPE as Incident-To

The IPPE is not subject to incident-to billing and payment rules, according to Frilling.

"From the questions we receive, we know that many of you are very familiar with Medicare policies for billing and payment of 'incident-to' services," Frilling says. "However, the payment policies for furnishing services incident-to a physician do not apply to the IPPE as this service has its own benefit category."

Instead, physicians and non-physician practitioners must meet specific benefit requirements for who may furnish IPPE in order to bill for the service, Frilling adds.

Resource: Download the CMS quick reference guide for incident-to services at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//MPS_QRI_IPPE001a.pdf.