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Family Practice Coding Alert

CMS' 2005 Rule Busts This Myth:

Medicare Never Covers Physical Exams

Code initial Medicare well-exams with G0344 A new Medicare benefit means your FP will finally get paid for some preventive medicine services - provided you know these rules. Report Medicare PE Services 2 Ways Starting Jan. 1, you'll have to code physical exams (PE) to Medicare recipients using two methods. "Coders are really going to have to pay attention when billing Medicare for preventive medicine services," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "The new Welcome to Medicare (WMT) benefit introduces a brand new coding concept."
 
Old method: You previously should have coded Medicare PEs with 99387 (Initial comprehensive preventive medicine evaluation and management of an individual ... 65 years and over) or 99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... 65 years and over). "Of course, you wouldn't bill Medicare for the non-covered service," says Callaway. You'd instead charge 99387 or 99397 to the patient.
 
If the family physician (FP) performed a well woman exam, you'd also code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory). "Medicare would reimburse these services," adds Callaway.
 
New way: When a patient is brand new to Medicare, you may code the first PE - dubbed the IPPE (initial preventive physical exam) - with G0344 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first six months of Medicare enrollment). Target Risk Factors With IPPE The age-appropriate exam that your FP performs in a PE focuses on different areas than an IPPE targets. Therefore, CMS valued the new service at a level equal to 99203, rather than 99387 or 99397.
 
Medicare intends the IPPE "to target selected modifiable risk factors and secondary prevention opportunities" that evidence shows "improve the health and welfare of the beneficiary," CMS states in 2005 Medicare Fee Schedule final rule.

In addition, when compared to 99397, the new benefit focuses less on a comprehensive physical examination, according to the final rule.
 
A few items that CMS' final rule says physicians should perform with an IPPE include:
  looking for "modifiable risk factors for disease," or conditions where early detection could make a huge difference;
  seeking information on a patient's diet, alcohol, tobacco and drug use and physical activities; and
  looking for risk factors for depression. Use IPPE-Specific ECG Codes Instead of 93000 The IPPE also includes a separately billable electrocardiogram (ECG). "But you won't use the normal 93000 (Electrocardiogram, routine ECG with at least 12 leads ...) series codes that you normally associate with an ECG," warns Callaway.
 
Instead: You should code the diagnostic procedure with G0366 (Electrocardiogram, routine ECG with at [...]


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