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Sorting Through Medicare Annual Wellness Visits, the IPPE and Preventive Services
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Sorting Through Medicare Annual Wellness Visits, the IPPE and Preventive Services

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Michigan Community Health Center billing staff and healthcare providers are encouraged to ...

Michigan Community Health Center billing staff and healthcare providers are encouraged to
participate in this training to learn the difference between Preventive Medicine Services, the
Medicare Annual Wellness Visit (AWV), and the Medicare Initial Preventive Physical Examination
(IPPE). Participants will learn information that will be helpful in determining when to use the specific
HCPCS codes as well as what combinations of codes can be billed together. Modifiers for use
with the HCPCS codes as well as diagnostic coding will also be covered.

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  • 1. Sorting through Welcome To Medicare Visit Annual Wellness Visit Preventive Services Jeanne P. Rutledge, CPC Medical Management Systems of MI, Inc.
  • 2. Objectives
    • Define:
      • Medicare Initial Preventive Physical Examination (IPPE)
      • Medicare Annual Wellness Visit (AWV)
      • Preventive Medicine Services
    • Explain Components/Elements that must be provided for each type of service
    • Review Documentation Requirements for each type of service
    Medical Management Systems of MI, Inc.
  • 3. Agenda
    • Definitions
    • Who is eligible and When
    • Documentation Requirements
    • ICD-9 Coding
    • HCPCS and CPT Billing Requirements
    • Available Resources
    • Questions?
    Medical Management Systems of MI, Inc.
  • 4. Definitions-IPPE
    • HCPCS versus Medicare
      • HCPCS G0402
        • “ Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment”
      • Medicare
        • “ Not a routine physical checkup…..”
    Medical Management Systems of MI, Inc.
    HCPCS Medicare
  • 5. Definitions-IPPE
    • Medicare Initial Preventive Physical Examination (IPPE)
    • ( Welcome to Medicare )
    • 7 Components
    • Only NEWLY enrolled (first 12 months)
    • One-time benefit
    • Coverage
      • From 1/1/09: Deductible waived
      • From 1/1/2011: Deductible and Copayment waived
    Medical Management Systems of MI, Inc.
  • 6. Definitions-IPPE
    • Closer look at 7 Components
    • Expanded Benefits #4 (ICN 006433 June 2011)
    • An examination to include:
        • Height, weight, BP, BMI
        • Visual acuity screen
        • And other factors as deemed appropriate…..
    • Quick Reference Information (ICN 006904 Feb. 2011)
    Medical Management Systems of MI, Inc.
  • 7. Definitions-IPPE
    • Who can furnish :
    • “ The IPPE must be furnished by either a physician or a qualified non-physician practitioner”
    • “ Yes, a physician assistant may furnish an (IPPE)” (Medicare Answer ID 10794 9/02/2011)
    Medical Management Systems of MI, Inc.
  • 8. Definitions-IPPE
    • What is NOT a Component
    • NOTE: “This exam is a preventive visit and not a “routine physical checkup” that some seniors may receive every year or two from their physician or other qualified non-physician practitioner.”
    • “ Medicare does not provide coverage for routine physical exams.”
    Medical Management Systems of MI, Inc.
  • 9. Definitions-IPPE
    • Diagnostic code reporting (ICN 006559 Feb. 2011)
    • No specific diagnostic code(s)
    • Contact local Medicare contractor for guidelines
    • Contact other carriers that indicate coverage for HCPCS code G0402
    Medical Management Systems of MI, Inc.
  • 10. Definitions-IPPE
    • Billing Requirements : (Answer ID 10800 09/08/2011)
      • “ Non-covered preventive services, including E/M services may be furnished with an IPPE visit.”
      • “ Provider should notify the patient that the additional services are non-covered by Medicare and the payment for the additional non-covered preventive services will fall to the beneficiary.”
      • “ Non-covered E/M preventive services will have substantial overlap with the service elements furnished in the IPPE…practitioners are responsible for billing appropriately”
    Medical Management Systems of MI, Inc.
  • 11. Definitions-IPPE
    • Billing Requirements (Answer ID 10690 06/15/2011)
      • “ Medicare payment can be made for a significant, separately identifiable medically necessary E/M service billed at the same visit at the IPPE, when billed with modifier –25.”
      • “ That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.”
    Medical Management Systems of MI, Inc.
  • 12. Definitions-AWV
    • HCPCS versus Medicare
    • HCPCS G0438
    • Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit
    • HCPCS G0439
    • Annual wellness visit; includes a personalized prevention plan of service (pps), subsequent visit
      • Medicare
        • “ Not a “routine physical checkup”…..”
    Medical Management Systems of MI, Inc.
  • 13. Definitions-AWV
    • Medicare Annual Wellness Visit
    • (AWV) Initial IPPE with
    • Personalized Prevention Plan Services (PPPS)
    • 9 Elements
    • Eligibility: No longer within initial 12 months
    • One-time benefit
    • Coverage
      • After 1/1/2011, Co-payment/Deductible waived
    Medical Management Systems of MI, Inc.
  • 14. Definitions-AWV
    • Medicare Annual Wellness Visit
    • (AWV) Subsequent IPPE with PPPS
    • 7 Elements
    • Eligibility: No IPPE/AWV within past 12 months
    • Used Annually
    • Coverage:
      • After 1/1/2012, Co-payment/Deductible waived
    Medical Management Systems of MI, Inc.
  • 15. Definitions-AWV
    • Initial
      • Closer look at 9 Elements
      • Bullet 2 (ICN 906623 July 2011)
        • Height, Weight, BMI, BP
        • Other routine measurements as deemed appropriate, based on the beneficiary’s medical and family history
      • Quick Reference Information (ICN 006904 Feb. 2011)
    Medical Management Systems of MI, Inc.
  • 16. Definitions-AWV
    • Subsequent
      • Closer look at 7 Elements
      • Bullet 2 (ICN 906623 July 2011)
        • Weight, BP
        • Other routine measurements as deemed appropriate, based on the beneficiary’s medical and family history
      • Quick Reference Information (ICN 905706 Feb. 2011)
    Medical Management Systems of MI, Inc.
  • 17. Definitions-AWV
    • Eligible providers of AWV with PPPS
    • (MLN Matters # MM7079)
      • A physician who is a doctor of medicine or osteopathy
      • PA, NP, or Clinical Nurse Specialist
      • Medical professional (including a health educator, registered dietitian, or nutrition professional or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician as defined in the first bullet point of this section.
    Medical Management Systems of MI, Inc.
  • 18. Definitions-AWV
    • What is NOT an Element
    • NOTE: “The AWV is a preventive wellness visit and is not a “routine physical checkup”, that some seniors may receive every year or two from their physician or other qualified non-physician practitioner.”
    • “ Medicare Part B does not provide coverage for routine physical examinations”
    Medical Management Systems of MI, Inc.
  • 19. Definitions-AWV
    • Diagnostic code reporting (ICN 006559 Feb. 2011)
    • No specific diagnostic code(s)
    • Contact local Medicare contractor for guidelines
    • Contact other carriers that indicate coverage for CPT code G0438 and G0439
    Medical Management Systems of MI, Inc.
  • 20. Definitions-AWV
    • Billing Requirements : (Answer ID 10801 09/08/2011)
      • “ Non-covered preventive services, including E/M services may be furnished with an AWV.”
      • “ Provider should notify the patient that the additional services are non-covered by Medicare and the payment for the additional non-covered preventive services will fall to the beneficiary.”
      • “ Non-covered E/M preventive services will have substantial overlap with the service elements furnished in the AWV…practitioners are responsible for billing appropriately..”
    Medical Management Systems of MI, Inc.
  • 21. Definitions-AWV
    • Billing Requirements (Answer ID 10674 6/14/2011)
      • “ Medicare payment can be made for a significant, separately identifiable medically necessary E/M service billed at the same visit at the IPPE, when billed with modifier –25.”
      • “ That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.”
    Medical Management Systems of MI, Inc.
  • 22. Definitions-IPPE & AWV
    • Billing Requirements (Answer ID 10802 09/09/2011)
    • “ CMS does not require providers to submit claims for non-covered services provided to a patient, at no charge.”
    • “ CMS notes that the decision on whether or not to charge a patient for non-covered Medicare services is at the discretion of each provider”
    Medical Management Systems of MI, Inc.
  • 23. Definitions-Preventive
    • Used to report preventive medicine evaluation and management of:
        • Infants, children, adolescents, and adults
    • Extent and focus of the services depend on age of the patient.
    • When abnormality is encountered/preexisting problem addressed AND is significant (requiring additional problem oriented E/M components) then ALSO report E/M.
    Medical Management Systems of MI, Inc.
  • 24. Definitions-Preventive
    • Evaluation and Management of an individual including;
      • Age and gender appropriate
        • History
        • Examination
        • Counseling/anticipatory guidance
        • Risk factor reduction interventions
    • Initial (99382-99387)
    • Periodic (99391-99397)
    Medical Management Systems of MI, Inc.
  • 25. Definitions-Preventive
    • Billing Requirements
    • Non-covered by Medicare
    • When billing with IPPE/AWV and/or E/M add Modifier –25
      • Indicates that a significant, separately identifiable E/M service was provided
      • …… .Was documented, mainly based upon Chief Complaint and HPI
    Medical Management Systems of MI, Inc.
  • 26. Work Flow
    • Determine your Internal Definitions
    • Inform Patients prior to appointments
      • Create short description of IPPE/AWV
      • Explain IPPE/AWV lack of Exam
      • Provide Brochures
    • Talk to patient about money
    • Documentation; AWV/IPPE separate from E/M service (standard forms utilized)
    Medical Management Systems of MI, Inc.
  • 27. Code Combinations
    • How does your EPM affect reporting
    • How does your EMR affect reporting
    • Visit type Options:
      • Preventive Medicine
      • Welcome to Medicare Physical
      • Annual Wellness Medicare, Initial
      • Annual Wellness Medicare, Subsequent
      • E/M Services
    Medical Management Systems of MI, Inc.
  • 28. Code Combinations Medical Management Systems of MI, Inc.
    Internal Name Welcome Visit Well Initial Well Subsequent Yearly Sick Visit Code Combo IPPE G0402 AWV-I G0438 AWV-S G0439 Prevent Exams CC/HPI for E/M 1 st 12-mts of Medicare YES NO NO YES YES G0402 992__ 993__ 13-mts after Medicare elig. No AWV Yet NO YES NO YES YES G0438 992__ 993__ 13-mts after Medicare elig. Had Initial AWV NO NO YES Yes YES G0439 992__ 993__
  • 29. Resources
    • Quick Reference Information
      • IPPE
      • AWV
      • Preventive Services
    • Brochures
      • Expanded Benefits-IPPE
      • Annual Wellness Visit
    • Medicare Learning Network
      • MLN # SE1129
      • MLN # MM7079
    Medical Management Systems of MI, Inc.
  • 30. Questions
    • Thank you for Participating Today
    • Medical Management Systems of MI, Inc.
    Medical Management Systems of MI, Inc.