Navigating the complexities of Medicare can be challenging, especially when it comes to preventive care services. As healthcare providers, it’s crucial to understand the specific coding and billing guidelines for services like the Initial Preventive Physical Examination (IPPE), often referred to as the “Welcome to Medicare” visit, and the Annual Wellness Visit (AWV). Correct ICD coding is not only essential for accurate claim submission but also for ensuring your patients receive the preventive care they are entitled to under Medicare.
This guide provides a detailed overview of ICD coding for “Welcome to Medicare” preventive care, focusing on the IPPE and AWV. We will delve into the components of each visit, the relevant HCPCS and CPT codes, diagnosis coding requirements, and billing procedures to help you optimize your practice and provide excellent care to your Medicare patients.
Understanding Medicare Preventive Services: IPPE and AWV
Medicare emphasizes preventive care as a cornerstone of maintaining beneficiary health and well-being. Two key preventive services covered under Medicare Part B are the Initial Preventive Physical Examination (IPPE) and the Annual Wellness Visit (AWV). While both are designed to promote wellness and disease prevention, they serve distinct purposes and are offered at different times for Medicare beneficiaries.
Initial Preventive Physical Exam (IPPE): The “Welcome to Medicare” Visit
The IPPE, or “Welcome to Medicare” visit, is a one-time preventive physical exam available to new Medicare Part B beneficiaries within the first 12 months of their enrollment. It’s designed as an introduction to Medicare’s preventive services and focuses on health promotion, disease prevention, and early detection.
Key Components of the IPPE:
- Review of Medical and Social History: This includes past medical and surgical history, current medications, family history, diet, physical activities, and social habits like alcohol, tobacco, and drug use.
- Depression Risk Factor Review: Assessing potential depression risk factors using standardized screening tools.
- Functional Ability and Safety Assessment: Evaluating the patient’s ability to perform daily activities, fall risk, hearing impairment, and home safety.
- Physical Exam: Measuring height, weight, BMI, blood pressure, balance, gait, and visual acuity.
- End-of-Life Planning (upon patient agreement): Providing information about advance directives.
- Review of Opioid Prescriptions: For patients with current opioid prescriptions, reviewing potential risks and non-opioid treatment options.
- Screening for Substance Use Disorders (SUDs): Reviewing SUD risk factors and providing referrals if necessary.
- Education, Counseling, and Referrals: Based on the assessments, providing tailored education, counseling, and referrals.
- Preventive Service Education: Creating a brief written plan for obtaining other covered preventive services, including a one-time screening electrocardiogram (ECG).
ICD Coding for IPPE:
While there isn’t a specific required diagnosis code for IPPE claims, you must report a diagnosis code consistent with the patient’s exam. This could be a general wellness code or a code reflecting any identified risk factors or conditions during the visit.
HCPCS Codes for IPPE:
- G0402: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment.
- G0403: Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report.
- G0404: Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination.
- G0405: Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination.
- G0468: Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv.
Billing for IPPE:
Part B covers the IPPE when provided by physicians and qualified non-physician practitioners. Importantly, Medicare waives the coinsurance, copayment, and Part B deductible for the IPPE (HCPCS code G0402). However, this waiver does not extend to the screening ECG (HCPCS codes G0403, G0404, or G0405). If a significant, separately identifiable Evaluation and Management (E/M) service is also provided, it can be billed with modifier 25.
Annual Wellness Visit (AWV)
The Annual Wellness Visit (AWV) is available to Medicare beneficiaries who have been enrolled in Part B for more than 12 months and haven’t received an IPPE or AWV within the past 12 months. The AWV focuses on developing or updating a Personalized Prevention Plan of Service (PPPS) and performing a Health Risk Assessment (HRA). AWVs are crucial for ongoing preventive care and health management.
Key Components of the AWV:
- Health Risk Assessment (HRA): Gathering patient self-reported information on demographics, health status, psychosocial and behavioral risks, and activities of daily living (ADLs).
- Establish/Update Medical and Family History: Documenting medical events, past history, and medication use.
- Establish/Update Providers and Suppliers List: Maintaining a list of all current healthcare providers and suppliers.
- Measurements: Measuring weight, BMI, and blood pressure.
- Cognitive Impairment Detection: Assessing for cognitive impairment.
- Depression Risk Factor Review: Similar to IPPE, reviewing depression risk factors.
- Functional Ability and Safety Level Review: Evaluating ADLs, fall risk, and safety.
- Establish/Update Written Screening Schedule: Creating a personalized screening schedule for the next 5-10 years based on guidelines and patient risk factors.
- Establish/Update Risk Factors and Conditions List: Documenting risk factors and recommending interventions.
- Personalized Health Advice and Referrals: Providing tailored advice and referrals to preventive counseling services or programs.
- Advance Care Planning (ACP) (optional): Discussing advance directives at the patient’s discretion.
- Review of Opioid Prescriptions: Similar to IPPE, reviewing opioid prescriptions and potential OUD risks.
- Screening for SUDs: Reviewing SUD risk factors and referrals.
- Social Determinants of Health (SDOH) Risk Assessment (optional, starting 2024): Assessing SDOH using a standardized tool.
ICD Coding for AWV:
Similar to the IPPE, there is no specific required diagnosis code for AWV claims. Report a diagnosis code that is consistent with the patient’s exam findings.
HCPCS Codes for AWV:
- G0438: Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit (for the first AWV).
- G0439: Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit (for subsequent AWVs).
- G0468: Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv).
- G0136: Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes (for optional SDOH Risk Assessment starting 2024).
CPT Codes for Advance Care Planning (ACP) as part of AWV (optional):
- 99497: Advance care planning 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: Advance care planning 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).
Billing for AWV:
Part B covers AWVs when performed by a range of providers, including physicians, qualified non-physician practitioners, and medical professionals directly supervised by a physician. Medicare waives the coinsurance, copayment, and Part B deductible for AWVs (G0438 and G0439). ACP (99497, 99498) and SDOH Risk Assessment (G0136), when billed with modifier 33 and on the same claim as the AWV, also have waived cost-sharing. Similar to IPPE, if a significant, separately identifiable E/M service is provided, it can be billed with modifier 25. AWV codes G0438 or G0439 can only be billed once in a 12-month period and not within 12 months of a previous IPPE (G0402).
Key Differences Between IPPE and AWV
Understanding the differences between the IPPE and AWV is crucial for proper coding and patient education.
| Feature | Initial Preventive Physical Exam (IPPE) | Annual Wellness Visit (AWV) |
|---|---|---|
| Purpose | Introduction to Medicare, health promotion | Personalized prevention plan, ongoing wellness |
| Timing | One-time, within first 12 months of Part B | Annually, after 12 months of Part B |
| Focus | Disease prevention and detection | Health risk assessment, prevention planning |
| Routine Physical | Not a routine physical exam | Not a routine physical exam |
Routine Physical Exams vs. Medicare Preventive Services:
It’s important to note that Medicare does not cover routine physical exams. Routine physical exams are typically comprehensive exams performed without relation to a specific illness or symptom. While some elements of routine physicals may overlap with IPPE and AWV components, routine physical exams are not a covered Medicare benefit, and patients will be responsible for 100% of the out-of-pocket costs.
Resources for IPPE and AWV Coding and Billing
For the most up-to-date information and detailed guidelines on ICD coding and billing for Welcome to Medicare preventive care services, refer to these resources:
- CMS.gov Medicare Preventive Services Page: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html
- Medicare Claims Processing Manual, Chapter 9: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c09.pdf
- CMS Office of Minority Health: https://www.cms.gov/priorities/health-equity/minority-health
- MAC (Medicare Administrative Contractor) Website: https://www.cms.gov/MAC-info
By understanding the nuances of ICD coding for Welcome to Medicare preventive care, including IPPE and AWV, healthcare providers can ensure accurate billing, optimize reimbursement, and most importantly, deliver essential preventive services that empower Medicare beneficiaries to maintain their health and well-being.
