Medicare Now Does Prevention

Until now, Medicare has paid physicians only for taking care of sick people, with a few exceptions. Namely, it doesn't do prevention.

Contrast that to commercial payers, who pay pretty happily for things like annual exams or routine screenings. It's the expensive stuff that managed care hates.

But, as of January 1, 2005, Medicare responded to the pleas of physicians and patients alike and began to reimburse for three additional preventive services:

• an introductory preventive-style visit for new Medicare beneficiaries,
• diabetes screening, and
• screening for heart disease.

The expanded coverage isn't ideal, but it beats not getting paid at all for services that simply make sense.

Here are the details on what Medicare expects you to do and how to bill for it.

Doing the IPPE

You can now provide a "Welcome to Medicare visit" or what Medicare calls an "Initial Preventive Physical Exam" (IPPE) to new Medicare beneficiaries.

Any patient who became eligible for Medicare on or after January 1, 2005 can have this exam (and have it paid for) one time in the first six months of his enrollment.

Doctors of medicine or osteopathy, physician assistants, nurse practitioners, and clinical nurse specialists (but not certified nurse midwives -- but, really, how many midwives see Medicare beneficiaries?) can provide and bill for the service using the brand new HCPCS code G0344.

Expect about $124 for each service.  This includes the payment for the IPPE and the EKG.

Patients will need to cover the deductible and coinsurance. Since the patient, by definition, is new to Medicare, most will still have deductibles to pay down. A Medigap or other secondary insurance policy might cover their part.

But you can't just do whatever you like during the exam. The exam must consist of:

• Review of an individual's medical and social history, with attention to modifiable risk factors for disease detection.
• Review of an individual's risk factors for depression, based on the use of any nationally accepted screening tool.
• Review of the individual's functional ability and level of safety, based on the use of screening questions or a screening questionnaire of your choice.
• Measurement of the individual's height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate by the physician or provider, based on the individual's medical and social history and current clinical standards.
• Performance and interpretation of an EKG.
• Education, counseling, and referral, as deemed appropriate by the physician or qualified NPP, based on the results of the review described above.
• Education, counseling, and referral, including a brief written plan such as a checklist, provided to the individual for obtaining the appropriate screening and other preventive services that are covered under current Medicare Part B benefits.

And, of course, you have to document it all, or it doesn't count. 

The IPPE requires two types of screening not normally included in preventive medicine: screening for depression and screening for functional ability. The actual exam itself is quite brief: height, weight, blood pressure, vision, plus other exams you think are appropriate.

  The required screening EKG and interpretation is also unusual but has to be done. If you can't do it in your practice, outsource it and include the findings in your documentation before you bill.

Bill the EKG separately from the exam. Use G0366 for the global EKG, and G0367 and G0368 for the technical and professional components, respectively. 

Finally, make sure your plan for the patient is written down. This may be a good time to invest in an EMR that can produce a report with a few clicks, if you anticipate doing a lot of these visits.

Billing for other services

You can bill for other covered services --  including those few other preventive services Medicare already paid for --  that you do during the same visit as the IPPE. For example, you'll often bill the IPPE and a pelvic and breast exam, HCPCS code G0101. Or obtaining and preparing a Pap smear, Q0091. Male patients get shorter shrift: digital rectal exams, G0102, are bundled into the visit and are not separately payable. 

CMS even allows you to bill an office visit, using CPT codes 99201-99215 with a -25 modifier, on the same day as the G0344 --  but don't expect seamless reimbursement. CMS originally wanted to limit the level of E&M visit that could be billed with the IPPE --  only levels 1 and 2. They figured that the IPPE really covered most of it. In the final rule, they got rid of this limit but cautioned providers that they would be reviewing level 4 and 5 visits with the G0344. Make certain that you aren't counting any  documentation elements twice -- once for the IPPE and again to figure out what level E&M to bill.

IPPE and ABN

Do you need an ABN (advance beneficiary notice) when performing the IPPE?  Sometimes. 

You never need an ABN if you are performing a second IPPE during the six-month period.  For example, if the patient had the service done by another provider or in another state, and you performed a second IPPE, you do not need an ABN to hold the patient responsible because the service is never covered.  You do need an ABN if you provide the service outside of the patient's six-month eligibility period in order to hold the patient financially responsible for the service.

Screening allowed

In addition to the "Welcome" exam, Medicare will cover screening for cardiovascular disease and diabetes, within certain parameters.
Cardiovascular screens are allowed every five years.

Use CPT codes for each covered component or bill for all three at once with panel:

• 82465: Total cholesterol
• 83178: HDL-cholesterol
• 84478: Triglycerides
• 80061: Lipid panel

Medicare also requires specific diagnosis codes:

• V81.0: Special screening for cardiovascular, respiratory, and genitourinary diseases, ischemic heart disease.
• V81.1: Special screening for cardiovascular, respiratory, and genitourinary diseases.
• V81.2: Special screening for cardiovascular, respiratory, and genitourinary diseases, other and unspecified cardiovascular conditions.

The laboratory should use a lab ABN if it believes the patient may have had the test more than once in the past five years.

Diabetes screening is only covered for patients CMS deems are at high risk for developing diabetes. Such at-risk patients can get the screening paid for once a year.

Patients with prediabetes -- defined as patients with a previous fasting glucose level of 100-125 mg/dL, or a two-hour post-glucose challenge of 140-199 mg/dL --  can get two screening tests per 12-month period.

Patients with diabetes aren't covered for screens --  you already know they have the disease.

These services are paid using existing CPT codes from the lab fee schedule.

• 82947: Glucose; quantitative, blood (except reagent strip)
• 82950: Post glucose dose (includes glucose)
• 82951: Glucose: tolerance test (GTT) three specimens, includes glucose

They require diagnosis code V77.1, special screening for diabetes mellitus.

Granted, none of these new benefits is ideal. You might wish the IPPE paid more or that you could screen more often. But a little improvement is better than none at all.

Betsy Nicoletti is the author of the "2005
Physician Auditing Workbook." She can be reached at betsy@vermontel.net or editor@physicianspractice.com.

This article originally appeared in the April 2005 issue of Physicians Practice.