Cut IPPE denials with a concerted focus on CMS’ 7-pronged requirements (May 2017)

By Richard Scott (Belinda Holmes as Contributor)

in May 1, 2017 Part B News: Patient Encounters

Focus more on the preventive aspects of the “Welcome to Medicare” visit instead of the physical exam components and you may steer your practice to more success with this oft-denied service.

Practices endured a 17% denial rate for G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment) in 2015, the latest year of available Medicare claims data. The $18.4 million lost to denials may be due to a common misconception of what the code entails.

“I think in a large part that’s because [practices think] it’s a comprehensive physical — and it’s not,” advises Belinda Holmes, president of Healthcare Management Consulting in Sarasota, Fla.

Medicare is specific about what it intends providers to achieve with the initial preventive physical examination (IPPE) and what practices need to report to get their claims through. “The goals of the IPPE are health promotion and disease prevention and detection,” states CMS in The ABCs of the Initial Preventive Physical Examination (see resources, below).

As far as physical exam components go, you have to capture only two elements: vital signs — including height, weight, body mass index and blood pressure — and visual acuity. “The rest is risk assessment, education and referrals,” says Holmes.

Check the right boxes to code successfully 

You can improve your G0402 reporting by getting up to speed on the precise elements that the code requires, which include depression screening, a functional assessment and end-of-life planning.

•• Use a checklist to ensure you’re meeting the necessary requirements.

“Build out a template for what’s required for this visit,” suggests Holmes. It doesn’t have to be an extensive document; you can keep it simple by listing the key areas that Medicare looks for from a reporting perspective. You can fit the entire checklist into a seven-point template [see checklist]. Just be prepared to fulfill the necessary elements. For example, you can use a standardized screening tool, such as one of the Patient Health Questionnaires (PHQ) for the depression screening portion of the IPPE visit.

If a patient is injured or disabled, do your best to report the necessary vitals. You’ll find guidance on rare situations you may encounter from a recent “Ask the Contractor” webinar from Palmetto GBA, the MAC covering North Carolina, South Carolina, Virginia and West Virginia. “What happens when a patient comes in and they’re wheelchair-bound and you’re not able to obtain [height, weight and BMI]?” asked a caller during the webinar. “Some patients can’t get out of a wheelchair; however, some patients are able to stand for weight and body mass. So because they are in a wheelchair does not necessarily mean those items are not obtainable,” replied a Palmetto representative. “In the very unusual instance when you’re not able to get those things, you should document your attempt to obtain those items and why you can’t obtain them.”

•• Ensure the patient has not received an IPPE before.

As an introductory benefit, G0402 is intended to be a literal Welcome to Medicare service — and that means you must bill it within 12 months of the start of a patient’s initial Medicare eligibility period. Check with your Medicare administrative contractor (MAC) to ensure the patient hasn’t previously received the IPPE service — if he or she has, you’ll face an automatic denial.

“I’ve got some docs who take a half hour or an hour to provide the IPPE, and they get their money taken back,” recounts Holmes. “And that’s rough.”

To cover your bases, you may want to ask any new patients whether they have moved recently just in case a different MAC covered the IPPE visit. That’s a common reason for denials, warns Margie Scalley Vaught, CPC, a consultant based in Chehalis, Wash. “Did the patient see someone else and they did the IPPE?” asks Vaught. If so, your claim will get denied.



Checklist courtesy of Belinda Holmes: