The Complete Guide to the IPPE Medicare Wellness Visit 

Read below for all the necessary IPPE codes, billing information, and examination steps.
 

Quick, What is the Initial Preventative Physical Examination (IPPE) Exam?

At its core, the Initial Preventative Physical Examination, or IPPE, is a review of all medical and social health history with additional preventive services and healthcare education. However, the IPPE does not include an extensive physical examination. This ‘exam’ or service, focuses more on health promotion and disease prevention and detection. The IPPE is an opportunity for physicians to improve the patient’s quality of care, create care coordination plans, and illuminate any health concerns.

Who Can Perform It?

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

What’s Covered?

  • The exam is covered only once within 12 months of first Part B enrollment
  • The patient will pay nothing (if provider accepts assignment)

Why the IPPE Matters for Rural Health Clinics

As many providers are aware, Rural communities have higher rates of chronic diseases and illnesses. But patients have less access to care and healthcare education. Many patients wait a long time to treat their illness, or don’t come into their nearest Rural Health Clinic until they are already sick. That’s why exams like the IPPE are so crucial to improving patient care and quality of life. Know that the patient engagement and education component to this exam can be done in tandem with other visits.  The IPPE is an opportunity to create change in the community through preventative medicine. 

Breaking Down the Initial Preventive Physical Examination (IPPE)

The IPPE is known as the “Welcome to Medicare” preventive visit. Medicare pays for 1 patient IPPE per lifetime, no later than the first 12 months after the patient’s Medicare Part B benefits eligibility date.

During a visit, you might recommend that a patient receives these services more often than Medicare offers, or you might recommend additional services that Medicare doesn’t cover. If this is the case, please ensure that patients understand they may pay some or all the cost. Communication is key to making sure patients understand why you’re recommending certain services, and whether Medicare pays for them.

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According to the 2019 Rural Health IT Survey, declining reimbursements along with improving billing processes and managing denials are two of the top three pain points healthcare organizations face.

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9 Components of the IPPE 

  1. Review the patient’s medical and social history
      1. At a minimum, collect information about:
          • Past medical and surgical history (experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments)
          • Current medications and supplements (including calcium and vitamins)
          • Family history (review of medical events in the patient’s family, including hereditary conditions that place them at increased risk)
          • Diet
          • Physical activities
          • History of alcohol, tobacco, and illegal drug use. For more information about Medicare Substance Use
            Disorder (SUD) services coverages, read on in this booklet.
  2. Review patient’s potential depression risk factors, including current or past experiences with depression or other mood disorders
      1. Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. Find more information on depression screening on this depression assessment website.
  3. Review patient’s functional ability and safety level
      1. Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations. Cover, at minimum, these areas:
            • Ability to perform Activities of Daily Living (ADLs)
            • Fall risk
            • Hearing impairment
            • Home safety
  4. Exam
      1. Measure:
            • Height
            • Weight
            • Body Mass Index (BMI) (or waist circumference, if appropriate)
            • Blood pressure
            • Visual acuity screen
            • Other factors deemed appropriate based on medical and social history and current clinical standards
  5. End-of-life planning, on patient agreement
      1. End-of-life planning is verbal or written information offered to the patient about:
            • Their ability to prepare a plan in case of an injury or illness prevents them from making health care decisions.
  6. Review current opioid prescriptions
      1. For a patient with a current opioid prescription:
            • Review their potential Opioid Use Disorder (OUD) risk factors
            • Evaluate their pain severity and current treatment plan
            • Provide information on non-opioid treatment options. Refer to a specialist, as appropriate. Find more information on pain management in the HHS Pain Management Report.
  7. Screen for potential Substance Use Disorders (SUDs)
      1. Review the patient’s potential risk factors for SUDs and, as appropriate, refer them for treatment. A screening tool isn’t required but you may use one.
      2. Find more information on the National Institute on Drug Abuse Screening and Assessment Tools Chart
  8.  Educate, counsel, and refer based on previous components
      1. Based on the results of the review and evaluation services in the previous components, administer appropriate education, counseling, and referral.
  9. Educate, counsel, and refer for other preventive services
      1. Include a brief written plan, such as a checklist, for the patient to receive after the visit:
            • A once-in-a-lifetime screening electrocardiogram (ECG/EKG), as appropriate
            • Appropriate screenings and other preventive services
              Medicare covers in the Annual Wellness Plan

IPPE Coding, Diagnosis, & Billing

Use these HCPCS codes to file IPPE and ECG/EKG screening claims:

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

G0468 – Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv 

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Diagnosis

You must report a diagnosis code when submitting an IPPE claim. Medicare doesn’t require you to document a IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Billing

Medicare Part B covers an IPPE when performed by a:

  • Physician (a Doctor of Medicine or Osteopathy)
  • Qualified Non-Physician Practitioner (NPP) (a Physician Assistant [PA], Nurse Practitioner [NP], or Certified Clinical Nurse Specialist [CCNS]

When you provide an IPPE along with a separately identifiable and medically necessary Evaluation and Management (E/M) service, Medicare might help cover the E/M service.  Report the additional CPT code (99201–99215) with modifier –25. 

IPPE FAQs

What are the other Medicare Part B preventive services?

  • Advance Care Planning (ACP) as an Optional AWV Element
  • Alcohol Misuse Screening & Counseling
  • Annual Wellness Visit (AWV)
  • Bone Mass Measurements
  • Cardiovascular Disease Screening Tests
  • Colorectal Cancer Screening
  • Counseling to Prevent Tobacco Use
  • Depression Screening
  • Diabetes Screening
  • Diabetes Self-Management Training (DSMT)
  • Flu, Pneumococcal, & Hepatitis B Shots and their Administration
  • Glaucoma Screening
  • Hepatitis B Screening
  • Hepatitis C Screening
  • Human Immunodeficiency Virus (HIV) Screening
  • Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
  • IBT for Obesity
  • Initial Preventive Physical Examination (IPPE)
  • Lung Cancer Screening
  • Medical Nutrition Therapy (MNT)
  • Medicare Diabetes Prevention Program (MDPP)
  • Prolonged Preventive Services
  • Prostate Cancer Screening
  • Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests
  • Screening for Sexually Transmitted Infections (STIs) & High Intensity Behavioral Counseling (HIBC) to Prevent STIs
  • Screening Mammography
  • Screening Pap Tests
  • Screening Pelvic Examination (includes a clinical breast examination)
  • Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)

Is the IPPE the same as a patient’s yearly physical?

No. The IPPE isn’t a routine physical that some older adults may get periodically from their physician or other qualified Non-Physician Practitioner (NPP). This exam is an introduction to Medicare and its covered benefits. Additionally, it focuses on health promotion, disease prevention, and detection to help patients stay well. The SSA explicitly prohibits Medicare coverage for routine physical examinations.

Are clinical laboratory tests part of the IPPE?

No. The IPPE doesn’t include clinical laboratory tests, but you may make appropriate referrals for these tests as part of the IPPE. 

Does the deductible or coinsurance/copayment apply for the IPPE?

No. Medicare waives both the coinsurance/copayment and the Medicare Part B deductible for the IPPE (HCPCS code G0402).
Neither is waived for the screening electrocardiogram (ECG/EKG) (HCPCS codes G0403, G0404, or G0405).

If a patient enrolls in Medicare in 2020, can they get the IPPE in 2021 if it wasn’t performed in 2020?

A patient who hasn’t had an IPPE and whose initial enrollment in Medicare Part B began in 2020 is eligible for an IPPE in 2021, as
long as it’s within 12 months of the patient’s first Medicare Part B enrollment effective date.

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