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How to bill for the new 'Welcome to Medicare' exam

From the January-February ACP Observer, copyright 2005 by the American College of Physicians.

By Brett Baker

Q: What is the "Welcome to Medicare" examination?

A: The new "Welcome to Medicare" exam is an initial preventive physical exam that, beginning Jan. 1, is covered by the Centers for Medicare and Medicaid Services (CMS) for all beneficiaries enrolled in Medicare Part B. Coverage for the initial preventive exam was mandated by Medicare reform legislation passed in 2003. Until now, Medicare did not pay for routine physical examinations or checkups.

Q: What does the new benefit cover?

A: Medicare will cover one initial preventive exam within the first six months of the effective date of a beneficiary's Part B coverage.

The CMS has defined the elements that must be part of the initial preventive exam. They include:

  • Comprehensive medical and social history review. This review should pay particular attention to modifiable disease risk factors. At a minimum, the medical history must include:

    • Past medical and surgical history, including illnesses, hospital stays, operations, allergies, injuries and treatments.

    • Current medications and supplements, including calcium and vitamins.

    • Family history, with a review of medical events in the patient's family, including diseases that may be hereditary or place the individual at risk.

      The CMS defines social history to minimally include a history of alcohol, tobacco and illicit drug use; diet; and social and physical activities.

  • Physical exam. This must include measuring the patient's height, weight and blood pressure, as well as a visual acuity screen and other factors based on the patient's medical and social history.

  • Potential risk for depression review. This review must include a patient's past experience with depression or other mood disorders, based on the use of an appropriate screening instrument, for patients without a current diagnosis.

  • Functional ability and level of safety assessment. This should be based on the use of an appropriate screening instrument.

  • Electrocardiogram (ECG). The exam covers performance and interpretation of an ECG.

  • Education, counseling and referral. The exam covers these services as deemed appropriate based on review results and evaluation services.

The exam also covers education, counseling and referral—including a written plan, such as a checklist—to help patients get appropriate screening and other preventive services covered separately under Medicare Part B. These include, but are not limited to:

  • pneumococcal, influenza and hepatitis B vaccines and their administration;
  • screening mammography;
  • screening Pap smear and pelvic exams;
  • prostate and colorectal cancer screening;
  • diabetes outpatient self-management training services;
  • glaucoma screening;
  • bone mass measurements;
  • medical nutrition therapy services;
  • cardiovascular screening blood tests; and
  • diabetes screening tests.

Q: Where can I find an "appropriate" risk for depression review and functional ability/level of safety assessment screening tool?

A: ACP recognized screening tool resources are available to College members online. These resources were compiled by the ACP Medical Knowledge and Education Division.

Q. What billing codes and payment rates are associated with the new benefit?

A: The CMS has created Healthcare Common Procedure Coding System (HCPCS) codes you can use to bill the exam.

The CMS also recognizes that not all physicians can perform an ECG in their office. Physicians can make alternative arrangements to make sure an ECG is performed, then include ECG results in the patient's record to complete—and bill for—the initial preventive exam.

The following are new HCPCS codes and payment rates:

  • G0344: Initial, face-to-face visit service limited to new beneficiary during the first six months of Medicare enrollment; payment is equal to 99203.

  • G0366: Electrocardiogram, routine ECG with at least 12 leads with interpretation and report, performed as a component of the initial exam; payment is equal to 93000. (You must report G0344 and G0366 if you furnish the complete initial exam.)

  • G0367: Tracing only, without interpretation and report, performed as an initial exam component, payment is equal to 93005.

  • G0368: Interpretation and report only, performed as an initial exam component, payment is equal to 93010.

Q: How do I bill other Medicare-covered preventive services?

A: The initial exam does not include other preventive services or items—like colorectal cancer screening—that are covered separately under Medicare Part B screening benefits. Physicians who furnish these preventive services or items should bill them using existing codes.

Q: How do I bill for a medically necessary service provided on the same day as the initial exam?

A: The CMS allows physicians to bill for a medically necessary evaluation and management (E/M) service furnished during the initial preventive exam. This portion of the service should be reported with the appropriate E/M service code selected from the 99201-99215 range, with the appended modifier -25.

The CMS had proposed to permit physicians to bill no greater than a level 2 (up to 99202, for example, or 99212) for a medically necessary E/M service provided during the same visit as the initial preventive visit. But it removed that restriction at the request of ACP and other physician organizations.

Physicians can also bill for screening and preventive services covered separately by Medicare Part B, if those are provided during the initial preventive exam.

Q: What medical record documentation is expected for the initial preventive physical exam?

A: The CMS states that E/M services should be documented according to the 1997 or 1995 documentation guidelines. The agency requires that screening tools used, ECG documentation, referrals and a written plan for the beneficary be included in the medical record, noting that the forms and methods should mirror those used in typical practice. The agency believes these requirements do not impose an additional burden.

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For more information

Educational materials about this new coverage are available directly to physicians and through Medicare carriers. You can order the CMS beneficiary handbook "2005 Medicare & You" online.

To download a documentation template for the Welcome to Medicare exam, visit the American Academy of Family Physician's web site at http://www.aafp.org/fpm/20050400/27howt.html.

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