Primary Care Coding Alert

Hint: Don’t forget to report additional preventive services separately.

When reporting an initial preventive physical examination (IPPE) or a “Welcome to Medicare” claim with G0402, it is easy to fall into a trap of getting confused over understanding what other services you can or cannot report with this HCPCS code.

Bust these four myths to arm yourselves with the right information, and ensure reporting success for every initial preventive physical examination of a patient.

Myth 1: Report G0402 For Every Medicare Patient’s First PE

Reality: Many coders carry the confusion about whether or not they can report an IPPE with G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment) when the patient is seeing their physician for the first time. Irrespective of whether or not the patient is seeing your physician for the first time for a preventive exam, reporting the visit with G0402 or another wellness visit code depends on the patient’s enrollment status with Medicare. You can report the preventive exam with G0402 only under the following circumstances:

• The patient has newly been enrolled with Medicare and 12 months have not yet passed from the time of enrollment.
• The patient has not had any other initial preventive physical exam, either with your physician or with any other physician, after having enrolled with Medicare.

So, if the patient has already had an initial preventive exam after enrolling with Medicare for which either you or any other physician has reported G0402, you cannot report an additional unit of G0402 again under any circumstances. “This is an once-in-a-lifetime benefit for Medicare beneficiaries,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. 

Coding tip:You cannot report G0402 if your physician conducts such an exam after the patient’s first 12 months following Medicare enrollment. If 12 months have already passed, then you should consider reporting it with an annual wellness visit code such as G0438 (Annual wellness visit; includes a personalized prevention plan of service, initial visit) or G0439 (Annual wellness visit; includes a personalized prevention plan of service, subsequent visit) rather than G0402.

“Medicare beneficiaries have a limited window of opportunity, which corresponds to their first 12 months of Medicare enrollment, to receive an IPPE. After that, you have to look at a code for a Medicare annual wellness visit or the CPT® code for a preventive medicine visit, depending on the nature of the encounter,” Moore adds. 

Myth 2: G0402 is Comprehensive of All Preventive Services

Reality: The initial preventive physical examination covers the following components and these should be provided for you to report G0402:

• 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
• An examination to obtain the following:

            o Measurement of height, weight, body mass index (BMI), and blood pressure
            o  Visual acuity screen
            o 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, counseling, and referral for other preventive services, which should include a brief written plan (such as a checklist) for obtaining (if appropriate) a screening electrocardiogram (EKG or ECG) and other screening and preventive services that Medicare covers.

So, even though G0402 includes some basic preventive services (such as a measurement of the height, weight, BMI, and blood pressure) and tests for visual acuity, it does not include other Medicare-covered preventive services or screenings that the physician furnishes during the IPPE visit. So, if your physician provides other preventive services or screening, for example, like an EKG, prostate cancer screening, or a screening Pap test and pelvic exam, you can report them separately.

“The key here is that while the IPPE includes referral for other Medicare-covered preventive and screening services, the actual provision of those services is separately reportable,” Moore observes. 

If your physician performs a screening EKG during the IPPE visit, you should report it using one of the following codes:

• 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.
  

Myth 3: You Cannot Report E/M Codes With G0402

Reality: Typically, an encounter for an initial preventive physical exam will not involve reporting any other E/M codes for the visit, becausethe visit is solely focused on preventionand screening. According to CMS commentary in the Federal Register, they do not expect to see many problem-oriented E/M services billed on the same date of service as the IPPE. However, if your FP did perform a problem-oriented E/M service, you can capture these services with the appropriate E/M visit code in addition to G0402 for the IPPE part of the visit.

As Correct Coding Initiative (CCI) edits bundle problem-oriented E/M codes into G0402 with the modifier indicator ‘1,’ you’ll have to append the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to be able to separately report both the codes for the same session.

“Although Medicare does not expect it to be common, the reality is that it is not uncommon for a beneficiary at an IPPE to say, ‘Oh, by the way . . .,’ and self-identify a problem for the physician to address or for the physician to identify a problem that needs to be addressed. In either case, the physician may choose to address the problem at that encounter rather than bringing the patient back for a separate visit. The CCI edits recognize this reality and allow physicians to report both services with an appropriate modifier (modifier 25) appended to the E/M code,” Moore explains. 

Myth 4: You Can Report G0402 Incident-to

Reality: The initial preventive physical examination is not subject to incident-to billing. The payment policy for furnishing services incident-to a physician do not apply to the IPPE, as this service has its own benefit category. If a non-physician provider such as a nurse practitioner performs either of these services, he must bill under his own NPI. 

You should note that physicians and non-physician practitioners must meet specific benefit requirements for who may furnish IPPE in order to bill for the service. If the requirements are not met, you are not allowed to report G0402 for non-physician practitioners by using incident-to billing.