Accurate coding of the Initial Preventive Physical Examination

It is important for internists to understand and plan for the Initial Preventive Physical Examination, a one-time visit for new Medicare beneficiaries.


With coding and payment policy constantly changing and updating, reminders can help office staff and clinicians code claims correctly so that payment is prompt. Several specific ways of handling coding for the Initial Preventive Physical Examination (IPPE), a one-time visit for new beneficiaries within the first 12 months of Medicare Part B enrollment, will ensure more accurate documentation and faster reimbursement.

The IPPE is a preventive wellness examination (not the routine physical head-to-toe examination, which Medicare does not cover). The IPPE is a review of:medical and social history, including potential risk factors for depression;

  • functional ability and level of safety;
  • measurement of height, weight, body mass index, blood pressure, and visual acuity; and
  • other factors deemed appropriate.

Education, counseling, and referrals based on results of review and evaluation of services performed during the IPPE may also be included, for example, a brief written plan such as a checklist. The IPPE could also include discussion of end-of-life planning if the patient agrees.

While there is some overlap with a routine physical exam, the focus of the IPPE is to furnish education counseling and prevention services that are appropriate for the individual and available in Medicare. The IPPE involves identifying health risk factors, taking routine measurements, and updating the beneficiary's medical record.

Photo by Thinkstock
Photo by Thinkstock

The IPPE must be performed within the first 12 months of the beneficiary's Part B coverage. Typically, the best time to schedule an IPPE exam is when the beneficiary's health status is stable and the patient is open to discussing preventive and screening services available in Medicare. To assist with maximizing the face-to-face time of the IPPE exam, inform the patient to be prepared and ready to discuss his or her medical history, current treatment, and medications and to discuss and develop a preventive screening schedule.

The IPPE is covered by Medicare Part B and can be furnished by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. The various components of the IPPE must be provided and documented in the beneficiary's medical record during the IPPE. However, with regard to the payment policy, furnishing services that are incident to a physician does not apply to the IPPE, because this service has its own benefit category.

Although a diagnosis code must be reported on the claim, no specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes are required for the IPPE. Therefore, Medicare clinicians should choose an appropriate ICD-9-CM diagnosis code. Examples of acceptable diagnosis codes that could be included on the claim are V70.0, V70.8, or V70.9, as well as any other valid, appropriate diagnosis codes. In summary, any appropriate diagnosis code would be acceptable for billing an IPPE.

Section 4104 of the Affordable Care Act (ACA) also waives cost sharing for many preventive services. Therefore, when preventive services, screenings, and laboratory tests are not included in the IPPE, they may be furnished during the visit if they are appropriate for the individual. This could provide a good opportunity to furnish or order preventive laboratory tests or give a flu shot. No modifier is required for billing other preventive services when they are furnished during the IPPE.

G0402 is the Healthcare Common Procedure Coding System (HCPCS) code for the IPPE. Section 4104 of the ACA waived the co-insurance and the deductible for this code. However, the deductible and co-insurance still apply to screening EKGs (G0403, G0404, and G0405) even though they may be done as a referral from an IPPE.

Typically, a diagnostic EKG cannot be performed on the same day as a screening EKG performed as a referral from the IPPE, unless the former is medically necessary. If a diagnostic EKG is performed on the same day as a screening EKG (G0403, G0404, or G0405) and is deemed medically necessary, then the diagnostic EKG must be billed with modifier 59. Screening EKGs are covered only once during a beneficiary's lifetime.

Another provision for beneficiaries receiving an IPPE is a one-time ultrasound screening for abdominal aortic aneurysm (AAA), which can be done as the result of an IPPE if the beneficiary has certain risk factors. The code for billing the AAA ultrasound screening is G0389, which is an ultrasound, B-scan, and/or real-time scan with image documentation. Section 4104 of the ACA waived the co-insurance and deductible for AAA screening (G0389) when performed with a referral from the IPPE visit.

When evaluation and management services are furnished during an IPPE visit, the practitioner must append modifier 25 to the claim line for payment. Cost sharing will apply to the evaluation and management service that is furnished during the IPPE, since the ACA only waives the cost-sharing requirement for the latter. However, the clinician should notify patients when additional services are not covered by Medicare and let them know that they will be responsible for payment.

Even though it is not a requirement, it would be good practice to use some documentation, such as an Advance Beneficiary Notice, to notify patients that they will need to pay for the additional noncovered service. When services substantially overlap with those furnished in an IPPE, practitioners are responsible for billing appropriately when providing additional noncovered services.