Initial Preventive Physical Exam (IPPE) and Annual Wellness Visit (AWV)

The following information is provided:

Initial Preventive Physical Exam (IPPE)

IPPE is an introduction to Medicare for a beneficiary who has started his/her Medicare coverage. It is more commonly known as the "Welcome to Medicare" visit. It is not a "routine physical" that some beneficiaries may want to have yearly. It gives a beneficiary an understanding of the Medicare-covered preventive services available.

The IPPE should be completed within the first 12 months of the effective date of the beneficiary's Medicare Part B coverage. It is a one-time benefit. If a beneficiary re-enrolls in Medicare, (i.e., Health Maintenance Organization, or HMO) he/she is not entitled to another IPPE. For example, if a beneficiary had Part B coverage from 2013 – 2015 due to ESRD, then turned 65 years of age in 2018, if the IPPE was not performed during the initial timeframe, the Annual Wellness Visit must be billed instead of the IPPE.

No specific diagnosis code is required and the deductible and coinsurance are waived.

The IPPE may be performed by a physician, nurse practitioner, physician assistant or clinical nurse specialist.

IPPE (HCPCS G0402) components include:

  1. Review of individual's medical and social history with attention to modifiable risk factors for disease detection
    • Medical/surgical/family history
    • Diet
    • Current medications and supplements
    • History of alcohol, tobacco and illicit drug use
    • Physical activities
  2. Review of potential risk factors for depression or other mood disorders
    • Using any appropriate screening instrument recognized by national professional medical organizations to obtain current or past experience with depression or other mood disorders
  3. Review of functional ability and level of safety
    • Hearing impairment
    • Activities of daily living
    • Fall risk
    • Home safety
  4. Examination to include:
    • Height
    • Weight
    • Body mass index
    • Blood pressure
    • Visual acuity screen
    • Other factors as deemed appropriate based on beneficiary's medical and social history
  5. End-of-life planning, upon agreement of individual
    • May either verbally discuss with the beneficiary or give written information about their ability to prepare an advance directive in the event that an injury or illness would cause him/her to be unable to make health care decisions and whether or not the provider is willing to follow the beneficiary's wishes
  6. Education, counseling, and referral, as appropriate, based on results of review and evaluation services
  7. Education, counseling and referral including brief written plan provided to the individual for obtaining appropriate screening and other preventive services

Medically necessary Evaluation and Management (E/M) services can be billed for at the same visit as the IPPE when clinically appropriate. Modifier 25 must be added to the E/M to show it is a significant, separately identifiable service from the IPPE.

Screening Electrocardiogram (EKG)

A once-in-a-lifetime screening EKG may be performed with a referral from an IPPE. There is no specific diagnosis code required. The deductible and coinsurance are not waived.
EKG HCPCS Codes

  • G0403 - EKG - interpretation and report (performed as screening for IPPE with interpretation and report
  • G0404 - EKG - tracing only (performed as screening for IPPE, without interpretation and report
  • G0405 - EKG - interpretation and report only (performed as screening for initial IPPE)

Annual Wellness Visit (AWV)

AWV is designed to develop and update the prevention plan tailored to the patient on an ongoing basis. It is not a "routine physical checkup" and takes place after a patient has his/her first IPPE. If the beneficiary is no longer within 12 months after the effective date of their first Medicare Part B coverage period and has not received either an IPPE or AWV within the past 12 months, Medicare will cover an initial AWV.

The AWV may be provided by physicians, nurse practitioners, physician assistants and certified clinical nurse specialists. Medical professionals, including registered nurses, health educators, pharmacists, registered dietitians, nutritional professionals or other licensed practitioners, or a team of such medical professionals, working under the direct supervision of a physician, may also provide the AWV, if their state licensure allows them to do all components of the service.

The AWV may be performed in a physician's office, inpatient or outpatient hospital, skilled nursing facility, critical access hospital or federally qualified health centers.

No specific diagnosis code is required and the deductible and coinsurance are waived. The AWV cannot be combined with the IPPE.

All the following elements must be completed to bill an AWV. If all are not provided, bill the most appropriate E/M code.

Initial AWV Components

The initial AWV (HCPCS G0438) is a one-time benefit and the components include:

  • Health risk assessment
    • Collects self-reported information about beneficiary
    • Can be administered independently by beneficiary or administered by health professional prior to or as part of encounter
    • Appropriately tailored to and takes into account the communication needs to underserved populations, persons with limited English proficiency and persons with health literacy needs
    • Takes no more than 20 minutes to complete
    • Addresses, at a minimum:
      • Demographic data, including but not limited to, age, gender, race and ethnicity
      • Self-assessment of health status, frailty and physical functioning
      • Psychosocial risks, including but not limited to, depression/life satisfaction, stress, anger, loneliness/social isolation, pain and fatigue
      • Behavioral risks, including but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (seat belt use) and home safety
      • Activities of Daily Living (ADLs), including but not limited to, dressing, feeding, toileting, grooming, physical ambulation and bathing
      • Instrumental Activities of Daily Living (IADLs), including but not limited to, shopping, food preparation, using the telephone, housekeeping, laundry, mode of transportation, responsibility for own medications and ability to handle finances
  • Establishment of:
    • Individual's medical/family history
    • Current providers and suppliers
  • Measurement of his/her height, weight, body-mass index (BMI) or waist circumference and blood pressure
  • Detection of any cognitive impairment
  • Review of individual's risk factors for depression, including current or past experiences with depression or other mood disorders, based on appropriate screening instrument for persons without a current diagnosis of depression
  • Review of individual's functional ability and level of safety based on direct observation or the use of appropriate screening questions or screening questionnaire
  • Establishment of:
    • Written screening schedule for individual, such as a checklist for the next five – 10 years, based on United States Preventive Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP) recommendations, the individual's health risk assessment, health status, screening history and age-appropriate preventive services covered by Medicare
    • List of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or underway for the individual, including any mental health conditions or risk factors
  • Furnishing of personalized health advice and referral, if appropriate, to health education or preventive counseling services aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention and nutrition.

Subsequent AWV Components

Components of subsequent AWVs (HCPCS G0439) include:

  • Review, and administration if needed, of updated health risk assessment
  • Update of individual's medical/family history
  • Update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual
  • Measurement of individual's weight or waist circumference, blood pressure and other routine measurements as deemed appropriate based on individual's medical/family history
  • Detection of any cognitive impairment that the individual may have
  • Update the following:
    • Written screening schedule for individual that was developed at the initial AWV, and
    • List of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual
  • Furnishing of personalized health advice to individual and referral, as appropriate, to health education or preventive counseling services or programs

Advanced Care Planning (ACP)

ACP is a face-to-face conversation between a physician, or other qualified healthcare professional, and a beneficiary to discuss the beneficiary's wishes and preferences for medical treatment if he or she were unable to speak or make decisions in the future for end of life care.

  • 99497 - ACP including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
  • 99498 - ACP including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

No specific diagnosis code is required. If ACP is performed alone, copayment and deductible are not waived. The copayment and deductible are waived if the ACP is furnished on the same claim as the AWV and billed with modifier 33, indicating preventive service.

All provider specialties may perform ACP and when furnished incident to, the state law and scope of practice requirements must be met and there must be a minimum of direct supervision. No frequency or place of service limitations apply; however, if done more than once, there needs to be a change in the beneficiary's condition to show medical necessity.

Other Services on Same Day

Generally, other medically necessary services may be provided on the same day as the IPPE and AWV; however, the National Correct Coding Initiative (NCCI) may indicate some services are not separately payable, such as the depression screening with IPPE or initial AWV.

 

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