The RCxRules Blog

New Year, New Preventive Medicine Benefits

The new year is the perfect time to encourage patients to take advantage of preventive medicine covered by their insurance. For Medicare patients, Medicare will cover two different types of wellness visits – the Medicare Initial Preventive Physical Exam (IPPE) and Annual Wellness Visits (AWV). Each visit has different CPT codes and coverage guidelines to follow to ensure coverage and payment. Here are the codes and guidelines for each visit:

Medicare Initial Preventive Physical Exam (IPPE)

  • Code: G0402
  • Description: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
  • Guidelines: The IPPE is a one-time benefit available to Medicare beneficiaries within the first 12 months of their enrollment in Medicare Part B. It includes a comprehensive assessment of the beneficiary's health status, including a review of medical and social history, physical examination, and education and counseling about preventive services.

Medicare Annual Wellness Visit (AWV)

  • Codes: G0438 (for the first AWV) and G0439 (for subsequent AWVs)
  • Descriptions:
    • G0438: Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit
    • G0439: Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit
  • Guidelines: The AWV is a yearly benefit available to Medicare beneficiaries who have had Medicare Part B for more than 12 months. It focuses on the development of a personalized prevention plan based on the beneficiary's health status and risk factors. The AWV includes a review of medical and family history, assessment of functional ability and cognitive impairment, and the creation of a written plan for preventive services.

It's important to note that these codes are specific to Medicare and may not be applicable to other insurance plans. Additionally, proper documentation and meeting the specific requirements outlined by Medicare are necessary for accurate coding and payment.

Did you know you can verify your patient’s eligibility for Medicare preventive services using your MAC’s provider portal or IVR system? When you know past dates of service or next eligible dates, you can:

  • Encourage your patients to get the preventive services they need
  • Better coordinate care with other health care providers
  • Help advance health equity

The next eligible date may be a future date, meaning you can’t provide the service until that date. Or it may be a past date, meaning your patient has been eligible for the service since that date and you can provide the service now. Medicare calculates eligibility dates from enrollment data and prior paid claims.

To learn more about how RCxRules can help specialty practices simplify their billing and coding to allow for more accurate and timely reimbursement, set up a 1:1 meeting today.


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