Introduction

Five Medicare Preventive Services

The Key to these codes:  No cost to the patient for preventive care

Accessing Medicare Preventive Codes in SETMA’s EMR

Determining Patient’s Eligibility for Medicare Preventive Visits

Required Elements for Medicare Preventive Visits

When a Required Element is Missing How to Fulfill it

How to “Calculate Code Eligibility”?

The Other Option - The Eligible Code is an IPPE

The IPPE and a Screening EKG

The IPPE and a Screening Abdominal Ultrasound

Additional Step for Ultrasound Completion

Submitting E&M Code Medicare Preventive Visits

General Concepts about Initial Preventive Physical Exam (IPPE)

Content of Annual Wellness Visit initial and Subsequent

CMS is getting serious about Preventive Health Services which have the potential for moving us toward the fulfillment of the Triple Aim:  improved care (processes), improve health (outcomes) and decreased costs (sustainability).  The new Intensive Behavioral Therapy codes for obesity and cardiovascular disease along with the Initial Preventive Physical Exam (IPPE), the Annual Wellness Visit Initial and Annual Wellness Visit Subsequent are significant advances in recognizing the value of preventive care and in recognizing the expertise of those who have the tools to provide those services. 

 Along with the Transitions of Care Management Codes which have been published this year, these preventive codes encourage the “right stuff” in primary healthcare delivery.   SETMA is determined to support and to promote these efforts by utilizing them in our practice.   The following is a link to our published deployment on our website of the Transitions of Care Management Codes which we are currently using in our almost 5,000 hospital discharges a year

The following references provide content information for Preventive Services authorized by Centers for Medicare and Medicaid (CMS). SETMA’s Clinical Decision Support (CDS) tools for these Preventive Services were developed on the basis of these and other official AMA and CMS publications.

1. The American Medical Association (AMA) owns the copyright to CPT (Current Procedural Terminology).  The Quick Reference Information Preventive Services is a summary of the Preventive Services authorized by Medicare (May 2012)
   
   http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/downloads/MPS_QuickReferenceChart_1.pdf


2. The following reference is to the AMA’s Quick Reference Information: the ABC’s of Providing the Initial Preventive Physical Examination (IPPE).
   
   http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf


3. The following reference is to CMS’s The ABCs of the Initial Preventive Physical Exam and the Annual Wellness Visit.
   
   http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ippe_awv_call_presentation.pdf

This tutorial will explain SETMA’s deployment of CDS Tools for the new Medicare Preventive Services:

1. Initial Preventive Physical Examination (IPPE or Welcome to Medicare)
2. Annual Wellness Examination (Initial) (AWV)
3. Annual Wellness Examination (Subsequent) (AWV)
4. Intensive Behavioral Therapy (IBT) for Obesity - this will be discussed in a subsequent tutorial
5. Intensive Behavioral Therapy (IBT) for Cardiovascular Disease - this will be discussed in a subsequent tutorial

Initial Preventive Physical Exam (IPPE) &Annual Wellness Visit (AWV)

Every patient encounter at SETMA begins on the AAA Home Template shown below with the review of the Pre-visit Preventive Screening.  When a Transitions of Care or a Medicare Preventive Visit is warranted, the type of visit is designated; depending on the patent’s need, this alert can say either:

• Patient Eligible for Transitions Care Management Exam
• Patient Eligible for Medicare Preventive Care Examination

If the patient is eligible for neither, nothing will appear in this place.  When one of these two notices is present, the provider knows that the patient has recently been discharged from the hospital and is eligible for Transition of Care Management Services, or that the patient is eligible for one of the Medicare Preventive Care evaluations.

Patient Eligible for Transitions Care Management Coding

Patient is eligible for a Medicare Prevention Visit

The following is the Evaluation and Management (E&M) template from SETMA’s electronic medical record with the codes for the Medicare Preventive Services - Initial Prevention Physical Examiner (Welcome to Medicare Visit) (IPPE) and Annual Wellness Visit Initial or Annual Wellness Visit Subsequent  (AWV) displayed. 

The key to these codes is that there is no deductible and CMS pays the provider for the full allowable benefit. This is a savings to patients and it is also a revenue benefit to the healthcare provider.  The payment for the IPPE is approximately $159 with no cost to the patient.  If a screening EKG and/or screening abdominal ultrasound is warranted and ordered at this time, the fee is paid in addition to the IPPE fee and it is paid without deductible, also. 

Outlined in green below, there are three preventive-care, wellness visit codes authorized by CMS.  They differ by when they are allowed to be performed and by the fact that in the case of the IPPE an EKG and an Abdominal Ultrasound can be ordered.  The code descriptions are:

• G0402 Initial Preventive Physical Examination (IPPE)  (Also called the Welcome to Medicare Preventive Visit )
• G0438 Annual Wellness Visit, Initial (AWV) Annual wellness visit, including a personalized prevention plan of service (PPPS), first visit.
• G0439 Annual Wellness Visit, Subsequent (AWV) Annual Wellness visit, including a personalized prevention plan of service (PPPS), subsequent visit. Annual Wellness Visits can be for either new or established patients as the code does not differentiate. The initial AWV, G0438, is performed on patients that have been enrolled with Medicare for more than one year.

The G0402 code denotes the Welcome to Medicare Visit (also called the Initial Preventive Physical Exam (IPPE).  It must be performed within one year of becoming eligible for Medicare and it is a once in the patient’s life-time benefit.  It is not for a routine physical examination and does not provide for payment of laboratory services except a screening EKG and, when the patient is qualified, an Abdominal Ultrasound for screening for an abdominal aortic aneurysm.  There are five codes related to the IPPE which are:

• G0402 Initial Preventive Physical Examination (Welcome to Medicare Preventive Visit )
• G0403 EKG with interpretation and report, performed as a screening for the IPPE
• G0404 EKG without interpretation and report
• G0405 EKG interpretation and report only
• G0389 Abdominal Ultrasound - once in a lifetime benefit - deductible waived, must meet criteria for screening (see below)

The following is the E&M Template with the code for the IPPE outlined in green.

Just above the three codes is a button entitled Eligibility (outlined in green below). 

When that Eligibility button is clicked, the Medicare Preventive Exam template appears. On this template all the elements of the three preventive care examinations appear.  In order to bill for any of the Medicare Preventive codes, all of the elements listed on this template must be fulfilled.  Until they are, if you click the Calculate Code Eligibility button, you will be informed that there is no code for which you can bill.

When any of the required elements are not fulfilled, they will appear in red as above.  In order to fulfill an incomplete element of the exam (those in red), simply click on the “Click to Complete” button to the right of each element which has not been met.   You will be taken to the place in the EMR where that evaluation can be completed and documented.  You will then be returned to the above template.  Once all of the elements are fulfilled - see the template below - all will turn black.

When you deploy the “Click to Complete” button next to the “visual acuity” element of the Medicare Preventive exam, you are taken to the template in SETMA’s EMR where the visual acuity is documented.  See below in green.

Once you document the visual acuity, click the “return” button at the top right of the template.

This takes you right back to the Medicare Preventive Exams template and now you see that the element in the exam - visual acuity - which was red is now black.

At this point, you click the “Calculate Code Eligibility” which is shown on the following template outlined in green. 

When the resulting eligibility code is an Annual Wellness Visit Initial (G0438) or an Annual Wellness Visit Subsequent (G0439), the following template will appear with the eligible code outlined in green.

At this point, click “OK.”  This action closes the Medicare Preventive Exam pop-up and the E&M template appears.

The E&M template shows that the correct G code has been selected.

All that remains is that the Submit button is pressed.  The correct code is then placed on your chart and sent to the central billing office.

The Other Option - the Eligible Code is an IPPE (G0240)

• When the patient is in his/her first year of Medicare benefits
• When all the elements for the Medicare Preventive Exams are completed
• When the “Calculate Code Eligibility” is deployed 
• When the code for which the patient is eligible is a G0402 (IPPE)

The following template will appear.  This template is different than the one for the Annual Wellness Visit because with the Initial Prevention Physical Exam, it is possible to order an EKG and/or an Abdominal Ultrasound.

The IPPE is a one-time, once in a life-time, benefit.  (Note:  The EKG and Abdominal Ultrasound are NOT allowed for an Annual Wellness Visit initial or on an Annual Wellness Visit Subsequent, but ONLY for an Initial Prevention Physical Exam.)

If an EKG is appropriate for the patient, it should be ordered by clicking on the box next to one of three options:

• You are doing an EKG, interpreting it and preparing a report.
• You are doing an EKG without interpretation or report.
• You are interpreting and preparing a report on an EKG which you did not perform.

Check the box beside the EKG service which applies to this encounter.  See below

Once you checked the correct EKG code, follow the below directions for determining if the patient qualifies for an Abdominal Ultrasound.  Once you have gone through the below process,  click OK.  This closes the IPPE Medicare Preventive Exam template. 

Without you performing any other function the EKG order has been added to the Radiology Template and it has been submitted to SETMA’s central billing office.  See below.

Determining whether the patient qualifies for an abdominal ultrasound

When the patient meets the criteria indicated below, they are eligible for an abdominal ultrasound. The criteria are:

1. Male
2. Between ages 65 and 75
3. Active smoker or with a history of smoking
4. Family history of aortic aneurysm

The algorithm is built into the tool and will tell you whether or not the patient is eligible. 

If the patient is found to be eligible for an abdominal ultrasound, an alert will appear which designates “patient is eligible for ultrasound” (see above in green).  Check the box next to the phrase, “Check here to order ultrasound.”  See below in green.

Once the visit type has been selected by clicking the Calculate Code Eligibility and if that code is G0402 (IPPE), after having completed the EKG and/or the Abdominal Ultrasound orders, click the OK button at the bottom of the Medicare Preventive Exams template shown above.   The code for which the patient is eligible by your documentation and by CMS’ criteria will automatically be placed on the Evaluation and Management template, as shown below.  Then click the “Submit” button outlined in green below for the charges to be posted.

Additional Step for Ultrasound Completion

For a Medicare beneficiary, an ultrasound does not need a referral.  But, since the ultrasound has to be done by ultrasonographers, at which time the charge is created, once the check box is selected on the preventive exam pop up, it automatically adds a note to the plan template to show the ultrasound was ordered.

The Ultrasound Department still needs to be notified of the test. This can be done in one of two ways:

• You or your nurse can call the ultrasound department and get them to schedule the procedure.
• You can complete a referral template so that there is a record of the order and it is handled within our system.

Sending a referral is structurally the best way to handle this process.  See the template below for how to send a referral for an abdominal ultrasound.

Once the referral is complete, the process is complete.  And, while the explanation is lengthy, the function is not.  The result is that thousands of Medicare beneficiaries are going to be getting important preventive health services at no cost to them. And, not unimportly, SETMA will receive addition revenue with which to continuing the purse of our mission to meet the healthcare needs of some of our most vulnerable neighbors.
. 
Can you bill CMS for a non-preventive care E&M code during the same visit in which you bill for a Medicare Preventive Visit? 

The answer is, “Yes,” with a couple of caveats, which are:

1. It must be done using a modifier -25. This has been built into this function and will automatically be added to your billing when you submit a Preventive Exam code and a routine E&M code, if a Medicare Preventive Visit and an another E&M code are billed in the same patient encounter.
2. Medicare Regulations state:  “Medicare may pay for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201 - 99215) billed at the same time as 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.”
3. The following is a private comment made by a physician:   “Considerable effort (has been spent) on this very issue with CMS directly so that MDs could do E/M visits at the time of the AWVs. The issue with the IPPE is the physical examination component, since for the current auditing, you need at least a 99213 PE for 99214 billing and the PE requirements for the IPPE have never been stipulated.  I do not recommend combining an E/M code with an IPPE for this reason but it is theoretically possible and frankly I would argue that spending added time with prevention and then dealing with the E/M is the right way to do this.”
4. CMS says they "may" pay for the Preventive Code and another E&M Code in the same visit BUT...The reality is the Preventive Code's intent is to provide a benefit to the patient at no cost and for the focus to be on PREVENTION.  Coincident to this preventive care, if you find an acute problem, or an exacerbation of a chronic problem, which places the patient's well-being at risk you can address that problem and bill for it. CMS "may" pay for that. BUT, you CANNOT just routinely tag a review of chronic conditions with routine laboratory tests on to a PREVENTIVE visit and expect it not to be denied. 
5. It is probably best under the current published criteria not to use an E&M code with an IPPE but it is allowable to do it with an AWV.

The following are general concepts which help explain the use of the IPPE (G0402)

• A patient who has just qualified for Medicare Part B is allowed this once in a lifetime benefit within the first 12 months of Medicare eligibility
• The IPPE does not include any clinical laboratory tests but referral for such tests may be part of the examination.
• Medicare may pay for a significant, separately identifiable medically necessary E/M service codes 99209-99205 billed at the same time as 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.
• You must report a specific diagnosis code for the IPPE; you may choose any appropriate diagnosis code.
• The deductible is waived for the IPPE
• Patient who is eligible for an IPPE cannot have an Annual Wellness Visit in the 12 months after the IPPE. 

Elements of IPPE

1. Review of Medical and Social History (SETMA’s History and Physical)
2. Review of beneficiary’s potential risk factors for depression and other mood disorders (SETMA’s Depression Questionnaire)
3. Review of the beneficiary’s functional ability and level of safety (SETMA’s Functional Assessment and Fall Risk)
4. Physical Examination (Height, weight, blood pressure, visual acuity screen, BMI, etc.)
5. End of life Planning (Code Status)
6. Education, counseling and referral based on the previous five components (SETMA’s plan of care and treatment plan)

Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) - patient must receive a referral for an AAA ultrasound screening as a result of an IPPE and must meet the criteria to have this screening ordered. Medicare will pay for this once in a lifetime benefit as long as your patient meets the following requirements:

• Beneficiaries at risk that have a family history of AAA
• Men age 65 to 75 who have smoked at least 100 cigarettes in their lifetime

Content of Annual Wellness Visit Initial (G0438)

In the second year of a patient being enrolled and/or eligible for Medicare, he/she is eligible for an Annual Wellness Visit.  This is paid at the rate of the 99214 visit which is approximately $101.  The difference is that once again, the entire fee is paid for by Medicare without any cost to the patient.

Content of G0438

• Medical/family history
• List of current providers/suppliers
• Blood pressure, height, weight, and other routine measurements.
• Detection of any cognitive impairment
• Review potential (risk factors) for depression, functional ability, and level of safety.
• Establishment of:

• Written screening schedule (such as a checklist) for next 5-10 years.
• List of risk factors and conditions where interventions are recommended.
• Personalized health advice and referrals for health education and preventive counseling

Annual Wellness Visit Subsequent (AWV) G0439

Content of G0439 Annual Wellness Visit, Subsequent (AWV)

• The Subsequent Annual Wellness Visit cannot take place until twelve months after the date of the Annual Wellness Visit Initial or after the last Annual Wellness Visit Subsequent.
• Update of medical/family history
• Update of list of current providers/suppliers
• Measurement of weight, blood pressure, and other routine measurements
• Detection of any cognitive impairment
• Update to:

• Written screening schedule
• List of risk factors and conditions where interventions are recommended.
• Personalized health advice and referrals for health education and preventive counseling