When your patients reach the age of 65, they have a decision to make: sign up for Medicare Part B, enroll in an HMO, PPO, EPO or pick another type of insurance. At age 65, patients may be automatically enrolled in Medicare Part A – with no sign-up required – which covers hospital, skilled nursing facility, hospice and some home health services. Medicare Part B, which covers physician and outpatient services, is voluntary and requires enrollment. Read more about Medicare coverage here.
If your patients choose to go on Medicare, they will be eligible to receive many different types of medical services and screenings; these are payable services for your practice, as well, and beneficial to the provider. These services are intended to promote health, prevention and detect early diseases. Most of the services do not require coinsurance and/or meeting the deductible waived and are available on the day the beneficiary’s Medicare Part B is effective; a few services, though, may only be covered if the patient is “high risk” or meets specific requirements.
Below are services for which your Medicare Part B beneficiaries are eligible, and which make your practice eligible for payment, too.
The first service we’ll review is the Initial Preventive Physical Exam (IPPE), which is commonly referred to as the “Welcome to Medicare” exam. Keep in mind that a beneficiary is only eligible for this service (CPT code G0402*) within the first 12 months of the Part B effective date and that it is covered only once per lifetime. This visit can be performed by a physician (MD or DO), physician assistant, nurse practitioner or certified clinical nurse specialist.
Here are the required components of the IPPE. (click here for a detailed description of each):
- Patient’s medical and social history (including opioid use)
- Patient’s potential risk factor for depression
- Patient’s functional ability and safety level
- Exam
- End-of-life planning
- Educate, counsel, refer based on results of review and evaluation
- Education, counseling, and referral for other preventive services including a brief written plan/checklist
*If an EKG with interpretation is done and documented at this visit, you can bill CPT code G0403, which includes the EKG and makes it unnecessary to report CPT 93000.
Another important service for Medicare beneficiaries is the Annual Wellness Visit, or AWV. Read more here. Two CPT codes are important for the AWV:
- G0438 for the initial, once per lifetime AWV
- G0439 for subsequent AWVs, one visit every 366 days. If you bill this code before the 366th day since the last AWV, the service will be denied.
During an IPPE or AWV, payment is also allowed (and billable) for an E/M Service (Evaluation and Management) when medically necessary and clinically appropriate. So, for example, if the beneficiary has a medical complaint, there is no need to schedule a separate visit or abandon the IPPE or AWV. The provider must document the visit complaint and associated actions, and can bill the E/M level appropriate for that part of the visit. The biller will append a modifier to assure proper payment.
CMS covers many different preventive services for Medicare beneficiaries, such as alcohol misuse screening and counseling. You can learn more about these by reading our individual blogs in Coding & Billing category (titled “Did you know…”) or watching our YouTube video on this topic.