Billing Wellness Visits Under Medicare, Part I

July 10, 2023

Nobody—and I mean nobody—welcomes an audit from CMS. That means taking extra care when assigning E/M codes to outpatient visits covered by Medicare. And with that in mind, the following three editions of Coffee & Coding will address a couple of questions submitted by a reader:

  • When can we bill an AWV, SWV, and initial physical exam?
  • Can we bill additional “sick visits” at the same time?

These are excellent questions that I’m sure we’ve all contemplated at some point. Now, let’s delve into them and provide clear explanations. Medicare covers three types of wellness visits:

  • The Initial Preventive Physical Examination (IPPE)
  • The first Annual Wellness Visit (AWV)
  • Subsequent Wellness Visits (SWVs)

In this week’s newsletter, we will examine and discuss the first category of IPPEs.

Initial Preventive Physical Examination (IPPE)

As the name suggests, this exam is designed to detect health issues and prevent them from becoming more serious (and subsequently more expensive to treat). An IPPE, also informally known as the “Welcome to Medicare” visit, must be conducted within the first 12 months after the patient becomes eligible for Medicare Part B benefits. Medicare provides coverage for only one IPPE during the patient’s lifetime.

Here, we present CMS’ guidelines outlining the components of an IPPE:

  • Review the patient’s medical and social history.
    • Past medical and surgical history, illness experiences, hospital stays, operations, allergies, injuries, and treatments.
    • Current medications and supplements
    • Family history
    • Diet
    • Physical activities
    • Alcohol, tobacco, and illegal drug use history ·
  • Review the patient’s potential depression risk factors, including history of depression or other mood disorders. Most commonly, this information is collected with a PHQ-9 question form. You’ll find information about less commonly used instruments for assessing depression here:
  • Exam (Remember, this is not a hands-on physical exam; it is all discussion; you gather information from the patient verbally).
    • Height, weight, body mass index, and blood pressure
    • Visual Acuity Screen (MUST be present and mandatory)
    • Other factors deemed appropriate based on medical and social history and current clinic standards.
  • End-of-Life Planning (following an agreement by the patient)
    • This is verbal or written information offered to the patient about their ability to prepare an advance directive in case of injury or illness that prevents them from making health decisions.
    • MOLST CPT 99497 is advance care planning, including the explanation and discussion of advance directives such as standard forms completed with the physician or other qualified health care professionals >16 minutes and up to 30 minutes face-to-face with the patient, family member, and/or surrogate.
      • This is scanned into the record and part of their chart.
  • Review current opioid prescriptions, risk factors/overuse, pain severity, treatment plan, and referral to a specialist for pain management.
  • Screen for potential substance use disorders.
  • Educate, counsel, and refer based on previous components and preventive services.

Now, let’s look at IPPE coding:

  • G0402: Initial preventive physical face-to-face within the first 12 months of Medicare enrollment.
  • G0403: Also use this code for the IPPE if this visit includes an electrocardiogram, and routine electrocardiogram (ECG) with 12 leads, performed as a screening.
  • G0444: A Mental health PHQ-9 usually is separately billable, EXCEPT for the IPPE, where it is included in the primary exam.

Here are the complete CMS guidelines for IPPE visits:

Look out for Part II, where we will dive into the guidelines for Annual Wellness Visits (AWVs).


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