Primary Care Coding Alert

The new year rings in good news for initial preventive physical examination (IPPE) revenue.

In response to physicians' claims that the exams involved more work than the code had been valued to include, CMS has increased the value of the "Welcome to Medicare" examinations. Moreover, more relaxed rules  in place since 2009 are kept unchanged, further increasing the dollar values for IPPE. Here's how to cash in on Medicare's gracious moves for 2010.

Medicare's big move for IPPE in 2010 is to greatly increase its work relative value units (RVUs).

Last year, G0402 (Initial preventive physical examination; face-to-face visit,services limited to new beneficiary during the first 12 months of Medicare enrollment) contained 1.34 work RVUs. In 2010, G0402 will now be worth 2.30 work RVUs, announced Kenneth Simon, MD, MBA, FACS, senior medical officer for CMS's Hospital and Ambulatory Policy Group at the CPT and RBRVS 2010 Annual Symposium in Chicago.

"I think the increase in the RVUs is excellent news," affirms Jannine Sherertz,CCS-P, clinical coding auditor and educator, Family Medical Center, Regional Services for CoxHealth, in Springfield, Mo., "These visits take a great deal of time for the providers to complete in order to meet all of the required components.

Code G0402's increased work RVUs puts this service's physician work value closer to 99204's (Office or other outpatient service for the evaluation andmanagement of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity...) work value of 2.43. Compare this to 2009, when the physician workRVUs for G0402 were as much as 99203 (... a detailed history; a detailed examination; medical decision making of low complexity...), which was 1.34.

Remember that last year, CMS had made two majorchanges to G0402. Make sure you know them.

First, as the G0402 descriptor indicates, a patient has 12 months from his enrollment date to receive an IPPE. Before 2009, new Medicare patients had a six-month window.

Second, the family physician is not required to perform an ECG for G0402, another major 2009 change that Simon confirmed for 2010. "The screening ECGs were probably removed because most patients have problems that will justify the ECG," shares Socorro Ramon, CPC, coding and audit manager for Universal American Corp. in Houston. "Or it may be that the ECG was deferred on many occasions and done at a later date and then many providers did not know how to bill for the ECG."

If the family physician does provide a patient with a "Welcome to Medicare" exam and an ECG during the same session, you can report them separately. On these claims, you'll report G0402 for the IPPE and one of the following ECG codes, depending on the specifics of the encounter:

• G0403 -- Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

• G0404 -- ... tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

• G0405 -- ... interpretation and report only, performed as a screening for the initial preventive physical examination.

CMS views G0402 as mutually exclusive of all problem E/M codes, which means that CMS will deny payment for a problem E/M provided at the same encounter as G0402 unless you bypass the edit by indicating that the problem E/M is significant and separately identifiable from the IPPE. Specifically, to bypass this edit, you'll have to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the problem E/M codes (e.g., 99201-99215).

As noted, Medicare rules do permit the preventive visit to be billed in addition to a significant problem addressed at the same visit. Think of it this way: "If an obgyn FP performs an IPPE on the same day as a sick visit, then Medicare will consider the sick visit bundled into theIPPE. However, you can still bill and be paid for the sick visit separately if you used a modifier 25 and -- what's vital -- have separate documentation to support it," Diane Wilkinson, director of quality assurance with MedSouth Healthcare in Dyersburg, Tenn., says.

Don't let this discourage your physicians from providing "Welcome to Medicare" exams. CMS has increased payment for G0402 to the approximate equivalent of 99204 (Office or other outpatient visit for the evaluation and management of a new patient ...).