Preventive Services

Preventive Services Guide

Initial Preventive Physical Examination

The IPPE is also known as the “Welcome to Medicare Preventive Visit.” The goals of the IPPE are health promotion and disease detection and prevention.

Table of Contents

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Coverage Criteria

  • One-time benefit for all newly enrolled Medicare beneficiaries
  • Must be performed within the first 12 months of initial Medicare effective date
    • Reenrolled beneficiaries are not eligible

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Components of IPPE

Component One – Acquire Beneficiary History – Medical and Social

  • Medical and social history with attention to modifiable risk factors for disease detection
    • Medical history (minimum)
      • Past medical and surgical history
      • Current medications and supplements
      • Family history
  • Social history (minimum)
    • History of alcohol, tobacco and illicit drug use
    • Diet
    • Physical activities
    • Social activities and engagement

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Component Two – Acquire Beneficiary History – Potential Depression Risk Factors

  • Potential risk factors for depression and other mood disorders must include current or past experiences with depression or other mood disorders
    • Standard screening tests recognized by national professional medical organizations are available

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Component Three – Acquire Beneficiary History – Functional Ability and Level of Safety

  • Must include hearing impairment, activities of daily living, fall risk, home safety
    • Standardized questionnaires recognized by national professional medical organizations are available

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Component Four – Examination

  • Must include, height, weight, blood pressure, visual acuity screen, body mass index, other factors deemed appropriate based on the beneficiary’s medical and social history and current clinical standards

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Component Five – End of Life Planning

  • Required only upon beneficiary’s consent
  • Verbal or written information
  • Ability to prepare advance directives
  • Whether or not physician willing to follow advance directive

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Component Six – Review of Current Opioid Prescriptions

  • Review their potential OUD risk factors
  • Evaluate their pain severity and current treatment plan
  • Provide information on nonopioid treatment options
  • Refer to a specialist, as appropriate

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Component Seven – Screen for Potential Substance Use Disorders

  • Review the patient’s potential risk factors for SUDs and, as appropriate, refer them for treatment. A screening tool is not required but you may use one.

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Component Eight – Educate, Counsel and Refer Based on Previous Components

  • Education, counseling, and make referrals based on first seven components

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Component Nine – Educate, Counsel and Refer for Other Preventive Services

  • Includes a brief written plan for screening EKG if appropriate, and other separately covered Medicare Part B screening and preventive services as applicable

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IPPE Billing – HCPCS

  • 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

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IPPE Billing – Diagnosis Code

  • Diagnosis code is required
  • Does not require a specific diagnosis code when billing IPPE and screening EKG
  • ICD-10 Codes

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Screening EKG

  • No longer a required component
  • If another physician or entity performs and/or interprets EKG
    • Rendering provider bills using G0403, G0404 or G0405
  • If an additional medically necessary EKG needs to be performed (same day as IPPE)
    • Bill using a CPT code in the 93000 series plus modifier 59
  • Deductible and coinsurance apply

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IPPE Documentation

  • Must show physician and/or qualified NPP performed, or performed and referred, all nine required components of IPPE
  • Use appropriate screening tools normally used in practice

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Who Can Perform?

  • Physician (MD or DO)
  • Qualified NPP (CNS, NP, PA)

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Cost Sharing for IPPE

  • Copayment/coinsurance waived
  • Deductible waived

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Reimbursement

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Nonparticipating Providers

  • Nonparticipating reduction applies
  • Limiting charge provision applies

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Additional Services

Other preventive services currently paid separately under Medicare Part B screening benefits are not included in IPPE

  • Allowed to be performed at same visit
  • Bill and document according to requirements for each preventive service
  • Depression screening (G0444) is not payable on the same day as the IPPE

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Evaluation and Management CPT codes 99202–99205 and 99211–99215

  • Must be medically necessary and separately identifiable
  • Report with modifier 25 when appropriate
  • Visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part

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Prolonged Preventive Services

  • Clock symbol next to CPT code G0402 in the MLN Educational Tool: Medicare Preventive Services indicates this code can be billed with a Prolonged Preventive Services add-on code.
  • Used when the service time exceeds the typical service time for the specific service
  • Must be a valid clinical reason included in the documentation to support the medical necessity of the additional time

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Common Claim Denials

  • Second IPPE billed for same beneficiary
  • IPPE was performed outside of first 12 months of first Medicare Part B coverage

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Related Content

Revised 10/1/2024