Medicare Advantage Medical Policy Bulletin

Section: CMS National Guidelines
Number: N-150
Topic: Initial Preventive Physical Examination (IPPE) Benefit (See Reference Section)
Effective Date: January 1, 2009
Issued Date: January 5, 2009

General Policy

The initial preventive physical examination (IPPE) is a preventive evaluation and management service (E/M) that includes:

  1. review of the individual’s medical and social history with attention to modifiable risk factors for disease detection;
  2. review of the individual’s potential (risk factors) for depression or other mood disorders;
  3. review of the individual’s functional ability and level of safety;
  4. a physical examination to include measurement of the individual’s height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate by the examining physician or qualified non-physician practitioner (NPP);
  5. education, counseling, and referral, as deemed appropriate, based on the results of the review and evaluation services described in the previous 4 elements;
  6. education, counseling, and referral including a brief written plan (e.g., a checklist or alternative) provided to the individual for obtaining the appropriate screening and other preventive services;
  7. education, counseling, and referral for an EKG, as appropriate;
  8. measurement of the individual’s body mass index; and,
  9. upon an individual’s consent, end-of-life planning.

Indications and Limitations of Coverage

Members are eligible for one IPPE (G0402) per lifetime, when provided during the first 12 months of the individual’s enrollment.

When the physician or qualified NPP provides a medically necessary E/M service in addition to the IPPE, codes 99201-99215 may be used depending on the clinical appropriateness of the circumstances. Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the initial preventive physical examination. When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.

NOTE:
Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary E/M service.

The IPPE does not include other preventive services that are currently separately covered. Examples include: pneumococcal, influenza and hepatitis B vaccines and their administration, screening mammography, screening pap smear and screening pelvic examinations, prostate cancer screening tests, colorectal cancer screening tests, diabetes outpatient self-management training services, bone mass measurements, glaucoma screening, medical nutrition therapy for individuals with diabetes or renal disease, cardiovascular screening blood tests, and diabetes screening tests.

In addition to the preventive exam, a once-in-a-lifetime screening EKG may be performed, as appropriate, with a referral from an IPPE during the 12-month enrollment period. If the EKG performed as a component of the IPPE is not performed by the primary physician or qualified NPP during the IPPE visit, another physician or entity may perform and/or interpret the EKG.

If the same physician or NPP needs to perform an additional medically necessary EKG in the 93000 series on the same day as the IPPE, report the appropriate EKG code. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

One ultrasound screening for abdominal aortic aneurysm (AAA), code G0389, is also eligible.

The IPPE may be performed by a doctor of medicine or osteopathy or by a qualified NPP (nurse practitioner, physician assistant and clinical nurse specialist).

Documentation Requirements

The physician and qualified NPP should use the appropriate screening tools typically used in routine physician practice. Physicians and qualified NPPs are required to use the E/M documentation guidelines to document the medical record with the appropriate clinical information.

All referrals and a written medical plan must be included in this documentation.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

992019920299203992049920599211
99212992139921499215G0402G0389
G0403G0404G0405   

Coding Guidelines

References

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-4, Chapter 12, Section 30.6.1.1

CMS Online Manual Pub. 100-4, Chapter 18, Section 110.1-110.3.3

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.