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Medicare coverage for Physical Examination services


Effective Jan 1, 2011 Medicare would cover Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS)

Medicare already covers “Welcome to Medicare” physical exam within the first 12 months for Part B beneficiaries that includes a one-time review of health, education and counseling about preventive services, and referrals for other care if needed.

CPT code to report this service is G0402 - Initial preventive physical examination IPPE; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment.

In addition to the above effective for the date of service on and after January 1, 2011 Medicare would cover a yearly wellness visit for the Medicare beneficiaries who has Part B coverage for longer than 12 months.

New CPT codes to report Annual Wellness Visit:

G0438 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit, (Short descriptor – Annual wellness first)

G0439 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit, (Short descriptor – Annual wellness subseq)

Report above codes with ICD V70.0

The beneficiary pay nothing for both IPPE and Annual Wellness Visit (AWV) if the doctor accepts assignment.

Billing Requirements:

1. The first yearly “Wellness” exam can’t take place within 12 months of “Welcome to Medicare” physical exam.

2. G0438 or G0439 must not be billed within 12 months of a previous billing of a G0402 (IPPE), G0438, or G0439 for the same beneficiary. Such subsequent claims will be denied with a CARC of 119 (Benefit maximum for this time period or occurrence has been reached) and a RARC of N130 (Consult plan benefit documents/guidelines for information about restrictions for this service).

3. If a claim for a G0438 or G0439 is submitted within the first 12 months after the effective date of the beneficiary’s first Medicare Part B coverage, it will also be denied as that beneficiary is eligible for the IPPE or “Welcome to Medicare” physical. Such claims with G0438 or G0439 will be denied with a CARC of 26 (Expenses incurred prior to coverage) and a RARC of N130.

Who can perform the new covered preventive service Annual Wellness Visit?

Coverage is available for an AWV when it is performed by a health professional. A health professional is defined as the following:

A physician who is a doctor of medicine or osteopathy; or

A physician assistant, nurse practitioner, or clinical nurse specialist; or

A medical professional (including a health educator, registered dietician, or nutritional professional or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician.

Also see Medicare coverage for Initial Preventive Physical Examination


Reference: http://www.cms.gov/MLNMattersArticles/downloads/MM7079.pdf


For a complete list of preventive services-related MLN Matters® Articles, please visit http://www.cms.gov/MLNProducts/Downloads/MLNPrevArticles.pdf

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