Welcome to Medicare Exam

June 1, 2008

We are just now starting to get patients from Medicare for their “Welcome to Medicare Exam.” I have heard that it is difficult to get these exams paid if you don’t use specific coding. However, I am unsure as to what the correct codes are. Can you help me?

Question: We are just now starting to get patients from Medicare for their “Welcome to Medicare Exam.” I have heard that it is difficult to get these exams paid if you don’t use specific coding. However, I am unsure as to what the correct codes are. Can you help me?

Answer: You need to use G codes.

Here are the basics of what is required and how to code:

Any patient who became eligible for Medicare on or after January 1, 2005, can have this exam (and have it paid for) one time in the first six months of his enrollment.

Doctors of medicine or osteopathy, physician assistants, nurse practitioners, and clinical nurse specialists (but not certified nurse midwives - but, really, how many midwives see Medicare beneficiaries?) can provide and bill for the service using the brand new HCPCS code G0344.

Expect about $124 for each service. This includes the payment for the IPPE and the EKG.

Patients will need to cover the deductible and coinsurance. Since the patient, by definition, is new to Medicare, most will still have deductibles to pay down. A Medigap or other secondary insurance policy might cover their part.

But you can’t just do whatever you like during the exam. The exam must consist of:

  • Review of an individual’s medical and social history, with attention to modifiable risk factors for disease detection.

  • Review of an individual’s risk factors for depression, based on the use of any nationally accepted screening tool.

  • Review of the individual’s functional ability and level of safety, based on the use of screening questions or a screening questionnaire of your choice.

  • Measurement of the individual’s height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate by the physician or provider, based on the individual’s medical and social history and current clinical standards.

  • Performance and interpretation of an EKG.

  • Education, counseling, and referral, as deemed appropriate by the physician or qualified nonphysician provider, based on the results of the review described above.

  • Education, counseling, and referral, including a brief written plan such as a checklist, provided to the individual for obtaining the appropriate screening and other preventive services that are covered under current Medicare Part B benefits.

And, of course, you have to document it all, or it doesn’t count.

The IPPE requires two types of screening not normally included in preventive medicine: for depression and functional ability. The actual exam itself is quite brief: height, weight, blood pressure, vision, plus other exams you think are appropriate.

The required screening EKG and interpretation is also unusual but has to be done. If you can’t do it in your practice, outsource it and include the findings in your documentation before you bill.

Bill the EKG separately from the exam. Use G0366 for the global EKG, and G0367 and G0368 for the technical and professional components, respectively.

Finally, make sure your plan for the patient is written down. This may be a good time to invest in an EMR that can produce a report with a few clicks, if you anticipate doing a lot of these visits. CMS provides a handy little checklist.