Documentation Criteria: Medicare Physicals

by  Jeanette Anderson, CPC CPMA
May 27th, 2016 - Reviewed/Updated Aug 16th

When billing annual Medicare physicals, it's very important to know the status of the patient, determining when they became eligible, and/or if they've seen another provider for any of these services as the initial visit codes are once in a lifetime codes and will be denied if they have already been billed for that particular patient. This information can be found by researching the patient's benefits on the Medicare website, www.medicare.gov.

Starting from the beginning, the Welcome to Medicare visit (G0402) also known as the Initial Preventive Physical Exam (IPPE) is Medicare's preventive E/M face to face visit. This code can only be used for the first twelve months from the date the patient became Medicare eligible. With this code, there are also additional initial screening EKG codes (G0403-G0405) that are also once in a lifetime codes. It is allowable to bill a regular EKG code if, for example, while taking a patients' vital signs palpitations were found. In this instance, medical necessity would support billing a regular EKG code (93000-93010).

Below are the documentation criteria that need to be met to support billing a G0402. These criteria are mostly verbal, aside from the exam:

• Review beneficiary's medical and social history

• Review potential risk factors for depression/mood disorders

• Review functional ability and level of safety

• Examine height, weight, blood pressure, visual acuity, BMI (body mass index) and other factors deemed appropriate

• End of life planning discussion Education, counseling, and referrals based on the previous components

• Education, counseling, and referral for other preventive services (i.e. colonoscopies, bone density tests, mammograms, etc.)

Beyond the Initial Preventive Physical (IPPE) time frame (12 months), you would move into billing for Medicare Annual Wellness Visits. This process begins with the once in a lifetime code G0438, known as the Initial Annual Wellness Visit which includes a personalized prevention plan of service (PPPS).

Below are the documentation criteria that need to be met to support billing a G0438. These criteria are mainly an overview and establishing patient history and well being:

• Health Risk Assessment (HRA) which addresses demographic data, a self-assessment of health status, psychosocial risks, behavioral risks, and activities of daily living.

• Establish the patient's medical and family history

• Establish a list of current providers and suppliers that are regularly involved in providing medical care to the patient

• Measure height, weight, blood pressure, BMI, and other routine measurements deemed appropriate based upon medical/family history

• Detect any cognitive impairment by direct observation

• Review risk factors for depression and/or mood disorders, past and present.

• Review functional ability and level of safety, which must include an assessment of hearing impairment, ability to successfully perform activities of daily living (ADLs), fall risk, home safety, etc.

• Establish a written screening schedule (i.e. checklist for the next 5- 10 years)

• Establish list of risk factors and conditions for which interventions are recommended or underway Furnish personalized health advice and a referral, as appropriate, to health education and counseling

Twelve months beyond the Initial Medicare Annual Wellness Visit would be the subsequent visit, or code G0439. This code would also include a personalized prevention plan of service (PPPS). Below are the documentation criteria that need to be met to support billing a G0439. These criteria provide updates to everything previously captured in the initial wellness visit:

• Review of health risk assessment (HRA)

• Update any medical or family history

• Update the list of current providers and suppliers involved in providing medical care to the patient

• Measure weight (or waist circumference), blood pressure, and other routine measurements deemed appropriate

• Detect any cognitive impairment by direct observation

• Update written screening schedule developed during the first Annual Wellness Visit (G0438)

• Update list of risk factors and conditions for which interventions are recommended or underway

• Furnish personalized health advice or any referrals as appropriate.

These codes are very different from your age-based periodic Comprehensive Preventative Visit (codes 99387 and 99397), which are not covered by Medicare. These Medicare physicals are heavily focused on record keeping of medical history and updates of the patient's wellbeing, focusing on preventive care. These physicals do not include clinical lab tests or screening which would be separately reportable. In addition, these codes can also be billed with a sick visit. For example, if a patient comes in for his/her annual wellness visit but also with complaints of abdominal pain, with enough documentation to support a significant separately identifiable E/M, the appropriate level of E/M with modifier 25 could be billed in addition to the Medicare physical.