Primary Care Coding Alert

Question: I've been billing an initial preventive physical exam for new Medicare enrollees as G0344 and the related electrocardiogram with G0366. What code should I use for existing Medicare patients?


Texas Subscriber


Answer: CMS offers the IPPE benefit (G0344, Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first six months of Medicare enrollment) with related ECG (such as G0366, Electrocardiogram, routine ECG with at least 12 leads ... performed as a component of the initial preventive physical examination) only to new Medicare patients. To take advantage of the covered service, patients must receive the service during the first six months that they join Medicare. No corresponding IPPE code with or without ECG exists for preventive physical exams provided to Medicare beneficiaries outside of their first six months of enrollment.

You should instead code a preventive physical exam and related ECG, as you previously did. Bill the patient for the preventive medicine service with 99387 (Initial comprehensive preventive medicine evaluation and management of an individual ... new patient; 65 years and over) or 99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... established patient; 65 years and over), assuming the patient is entitled to Medicare on the basis of age.

You should report the ECG with 93000-93010 (Electrocardiogram, routine ECG with at least 12 leads ...). If the FP performs the ECG for screening purposes, Medicare will cover the test only as an IPPE benefit. When the FP orders a screening ECG after this period, have the patient sign an advance beneficiary notice before the physician provides the test. Collect the fee from the patient when you receive the subsequent denial from Medicare.

Be careful: Don't assign G0366 for an existing Medicare patient. The G code is specifically for ECGs that the FP performs with the IPPE.

Example: A 65-year-old established patient presents for her annual well-woman check after her enrollment period expires. The FP also collects a screening Pap smear and performs a pelvic exam, clinical breast check, and ECG. Medicare covers all these services minus the screening ECG for the patient. You should submit the following codes to:

Medicare:
  G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) linked to V76.2 (Special screening for malignant neoplasms; cervix) for a low-risk beneficiary, or V15.89 (Other specified personal history presenting hazards to health; other)  for a high-risk beneficiary
  Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) with V76.2 or V15.89
  93000-93010 (ECG) linked to V81.2 (Special screening for cardiovascular, respiratory and genitourinary diseases; other and unspecified cardiovascular conditions) (When you receive the denial, bill the patient for this service.)

The patient:
  99397 (established patient preventive medicine service) with [...]