How to code for the new Medicare benefit

April 22, 2005

To get reimbursed for this new benefit, you have to sweat all the details. We tell you how.

Beginning Jan. 1 of this year, Medicare is offering a new benefit: an initial preventive physical exam for new enrollees. The once-a-lifetime IPPE or "Welcome to Medicare" exam must be scheduled within the first six months of an individual's enrollment in Part B (the enrollment must begin on or after Jan. 1, 2005). Part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the exam signifies a new focus on prevention. (For official instructions issued to the carriers, see Transmittal 417, CMS Manual System Pub. 100-04, http://www.cms.hhs.gov/manuals/pm_trans/R417CP.pdf.)

This new focus is good news for both patients and doctors. But to ensure that you're reimbursed for the Welcome to Medicare exam, you have to meet CMS's numerous requirements. We spell them out here.

The initial exam must have the following components:

"We're allowing the professional organizations to recommend tools that are appropriate," says attorney Leslie Norwalk, deputy administrator of CMS. "That allows doctors to determine what makes the most sense in their own setting rather than have CMS review every test." If the patient screens positive for depression, you need to counsel, educate, refer, or treat.