Author Topic: Welcome to Medicare issues  (Read 3022 times)


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Welcome to Medicare issues
« on: March 04, 2014, 01:17:08 PM »
I am a biller in training, and the Family Practice I work for has NEVER been paid for a "Welcome to Medicare" visit! We have been researching all the G codes to see what MIGHT be covered, and attempted our first "trial" with one of the PA's family members. This is what we billed for w/ DX codes for each CPT code:

G0402 (IPPE):
 - v70.0, (General medical examination)
 - v81.0, (Special screening for cardiovascular, respiratory & genitourinary diseases; ischemic heart disease)
 - v81.1, (Special screening for cardiovascular, respiratory & genitourinary diseases; hypertension)
 - v77.1, (Special screening for endocrine, nutritional, metabolic & immunity disorders; diabetes mellitus)

90670 & G0009 (PCV13 vaccination) :
 - v05.8, (Need for prophylactic vaccination; other specified disease)

G0403 (EKG for IPPE):
 - v81.0 (Special screening for cardiovascular, respiratory & genitourinary diseases; ischemic heart disease)

90715 & 90471 (Tdap vaccination):
 - v06.5 (Need for vaccination;td)

Does this all look ok for an IPPE visit? Now that I'm looking at this I believe we do not have a high enough "level of specificity" on the PCV13 code, AND the Tdap code doesn't look like the right one?

I am so new to billing and SO confused with Medicare processes, and both our Biller and our Providers need help on these so we can start performing these correctly, and bill for them correctly!



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Re: Welcome to Medicare issues
« Reply #1 on: March 04, 2014, 03:18:41 PM »
The best explanation PDF I've found to date on this from the AMA, it is no longer on their website but I have a copy, this is my personal website URL if you're wondering what the heck sheep have to do with Medicare:

Here's my quick and dirty explanation for the difference between the IPPE and AWV and when to bill which HCPCS code:

Initial Preventive Physical Exam = Both medical/social history, screenings for depression and functional ability (e.g. falls in the home, ease of movement in the home) and an actual physical with specifics based on patient history/need. Also end of life planning, if the patient is interested. It's called an "INITIAL Physical Exam" because this exam is only available once, and must be done within 12 months of the patient becoming eligible for Medicare Part B. If it occurs outside of this limited time period, it will be denied (which may be adding to confusion).

HCPCS Code = G0402

Annual Wellness Visit = The subsequent annual visits that can begin 12 months after Medicare Part B coverage begins. Physical exam will be tailored the the patient's individual history, but generally should include height, weight, BMI, and other standard vitals at the very least. A list of current providers and medications should be taken, all the screenings from the IPPE should be re-visited as should screenings for cognitive impairment. A plan should be created for the next 5-10 years to establish a screening schedule based on age-appropriate services and patient need.

HCPCS Code = G0438 (first visit) G0439 (every subsequent visit)

ICD V70.0 is correct for the IPPE, actually Medicare does not really have a specified "must use" ICD for this code so as long as you have the V70.0 it should be fine.

For the 90670 and G0009, the ICD we always use is V03.82; Medicare will cover this once in a lifetime and may cover additional vaccinations based on risk. If billing both G0009 and G0008 in the same visit, the ICD for all codes should be V06.6

G0403 is no longer considered a mandatory screening, and will only be covered once in a lifetime as a result of a referral made during the IPPE (and should be billed along with the IPPE). I've never billed this code so I'm not sure about ICD's. I think the important part is the referral.

90715/90471 is supposed to be covered if there is a documented injury or illness (like the patient stepped on a rusty nail), but if it is administered preventatively it's billed to Medicare Part D, and the patient is supposed to pay upfront and then will be reimbursed by their Medicare Part D plan. See this article for more info on this distinction: In this case you may want to just have the patient receive the vaccine at a pharmacy because they can bill Medicare Part D directly.

Final note - if the patient starts getting problem-focused (which happens a lot), the physician can bill an E&M code along with the IPPE or AWV and be reimbursed for both, as long as the E&M code has a modifier 25.

PS - This trips up everyone! Medicare defines things like "preventive care" much differently than any other health plans.
« Last Edit: March 04, 2014, 03:22:50 PM by shanbull »


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Re: Welcome to Medicare issues
« Reply #2 on: March 04, 2014, 09:29:04 PM »
Shelby - upon re-reading, I see that my comments applied to the annual wellness physical, not the "Welcome to Medicare" physical.  My bad.  I've deleted my comments but will leave the links below in case they can be of benefit to someone.

These links might give some perspectiveon the IPPE.  There are codes in both.

The follow comments apply more to the Annual Wellness Exam.
« Last Edit: March 04, 2014, 10:26:57 PM by RichardP »