9/2/2014 DISCLAIMER IPPE

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1 DISCLAIMER The information provided in this presentation was current as of September 2, Any changes or new information superseding the information in this presentation are provided in articles with publication dates after September 2, 2014, posted on our website at: CPT only copyright 2012 American Medical Association. All rights reserved. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright 2012 American Dental Association (ADA). All rights reserved. 2 IPPE Initial preventive physical examination (IPPE), or Welcome to Medicare Visit (WMV) is a preventive evaluation and management service (E/M) One-time benefit Not the same as a patient s yearly physical Does not include any clinical lab tests No deductible or coinsurance The ABCs of Providing the Initial Preventive Physical Examination (IPPE) MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf 3 1

2 IPPE G0402: Initial preventive physical examination Face-to-face visit Limited to new beneficiary during the first 12 months of Medicare enrollment 4 WHO CAN PERFORM THE IPPE? Physician (doctor of medicine or osteopathy) Qualified non-physician practitioner (PA, NP, CNS) 5 COMPONENTS Examination Acquiring patient history Counseling 6 2

3 IPPE FIVE EXAM ELEMENTS Review of the individual s 1. Medical and social history with attention to modifiable risk factors for disease detection 2. Potential (risk factors) for depression or other mood disorders 3. Functional ability and level of safety 7 EXAM ELEMENTS 4. Physical examination to include: Measurement of the individual s height Weight Blood pressure Visual acuity screen Other factors as deemed appropriate based on the patient s medical and social history and current clinical standards. 5. End of life planning 8 COUNSELING ELEMENTS Education, Counseling and Referral based on: Previous exam elements; and Other preventive services Includes a brief written plan (i.e. checklist) to be given to the patient for obtaining other Medicare covered preventive services 9 3

4 EKG CODES HCPCS Code G0403: Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report G0404: Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination G0405: Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination Short Descriptor EKG for initial preventive exam EKG tracing for initial preventive exam EKG interpret & report preventive exam 10 ANNUAL WELLNESS VISIT (AWV) The AWV is an annual Medicare preventive physical examination, available for eligible beneficiaries, and identified by HCPCS codes: G0438 (Annual wellness visit, including Personalized Prevention Plan Services [PPPS], first visit) G0439 (Annual wellness visit, including PPPS, subsequent visit) 11 TIME FRAMES Medicare covers an AWV for all beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period; and Who have not gotten either an IPPE or an AWV providing PPPS within the past 12 months At least 11 months have passed following the month in which the IPPE or the last AWV was performed). Medicare pays for only one first AWV per beneficiary per lifetime, and pays for one subsequent AWV per year thereafter. 12 4

5 WHO MAY PERFORM THE AWV? A physician (a doctor of medicine or osteopathy) Qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist), or a medical professional including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of such medical professionals who are working under the direct supervision of a physician, must furnish the AWV 13 HCPCS G0438 AWV service (G0438) is a one-time only Medicare benefit AWV covered for beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period and who have not gotten either an IPPE or an AWV within the past 12 months At least 11 months have passed following the month in which the IPPE or the last AWV was performed). Medicare pays for only one first AWV per beneficiary per lifetime, and pays for one subsequent AWV per year thereafter. 14 BENEFICIARY HISTORY Beneficiaries History Health Risk Assessment Collects information from patient and can be done before or during AWV Typically no more than 20 minutes 15 5

6 HEALTH RISK ASSESSMENT Addresses the following topics: Demographic data; Self-assessment of health status; Psychosocial risks; Behavioral risks; Activities of daily living (ADL) includes but not limited to: dressing, bathing, and walking; and Instrumental ADLs including but not limited to: shopping, housekeeping, and handling finances 16 BENEFICIARY HISTORY Establishment of the individual s medical/family history Review of the potential risk factors for depression, including current or past experiences with depression or other mood disorders Review of functional ability and level of safety 17 ASSESSMENT Obtain: Height; Weight; Body mass index (or waist circumference, if appropriate); Blood pressure; and Other routine measurements as deemed appropriate based on medical and family history Establish list of current providers and suppliers Detect any cognitive impairment 18 6

7 COUNSELING Establish a written screening schedule for patient, such as a checklist for the next 5 to 10 years, as appropriate for patient 19 COUNSELING (CONT.) Establishment of a list of risk factors and conditions of which primary, secondary, or tertiary interventions are recommended or underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits 20 COUNSELING (CONT.) Furnish personalized health advice and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management or communitybased lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition 21 7

8 SUBSEQUENT AWV SERVICES - HCPCS G0439 Include the following key elements furnished to an eligible beneficiary by a health professional Update to the individual s medical /family history Measurements of an individual s weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individual s medical and family history 22 SUBSEQUENT AWV SERVICES - HCPCS G0439 Updates list of the current medical providers and suppliers that are regularly involved in providing medical care to the individual as that list was developed for the first AWV providing PPPS Detection of any cognitive impairment 23 SUBSEQUENT AWV SERVICES - HCPCS G0439 Update to the individual s written screening schedule as developed at the first AWV providing PPPS Update to the individual s list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, as that list was developed at the first AWV providing PPPS Furnish appropriate personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs 24 8

9 AWV QUICK REFERENCE GUIDE The ABCs of Providing the Annual Wellness Visit (AWV) Learning-Network- MLN/MLNProducts/downloads/AWV_Chart_ICN pdf 25 OTHER E/M SERVICES ON SAME DAY A significant, separately identifiable, medically necessary E/M may be covered on same day ( ) as IPPE or AWV Modifier 25 when appropriate Appended when appropriate to the E/M service Documentation must indicate medical necessity To treat the illness or injury, or to improve function of a malformed body member 26 E/M SERVICE FURNISHED DURING THE SAME ENCOUNTER AS AN IPPE OR AWV Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable, E/M service 27 9

10 OTHER SERVICES ON SAME DAY Generally, you may provide other medically necessary services on the same date of service as an AWV Deductible and coinsurance/copayment apply for these other medically necessary services 28 OTHER COVERED SCREENING/PREVENTIVE SERVICES Abdominal Aortic Aneurysm Screening Alcohol Misuse Screening and Behavioral counseling Intervention in Primary Care Annual Wellness Visit Bone Mass Measurements Cancer Screenings Breast Cancer (mammograms and clinical breast exam) Cervical and Vaginal Cancer (pap test and pelvic exam [includes the clinical breast exam]) Colorectal Cancer Fecal Occult Blood Test Flexible Sigmoidoscopy Colonoscopy Barium Enema Prostate (PSA blood test and Digital Rectal Exam) 29 CONTINUED Cardiovascular Disease Screening Depression Screening in Adults Diabetes Screening Diabetes Self-Management Training Glaucoma Screening Human Immunodeficiency Virus (HIV) Screening Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B) Initial Preventive Physical Examination (IPPE) (also commonly referred to as the Welcome to Medicare Preventive Visit) Intensive Behavioral Therapy for Cardiovascular Disease Intensive Behavioral Therapy for Obesity Medical Nutrition Therapy (for beneficiaries with diabetes or renal disease) Sexually Transmitted Infections (STIs) Screening and High-Intensity Behavioral Counseling (HIBC) to prevent STIs Tobacco-Use Cessation Counseling

11 REFERRAL FOR ABDOMINAL AORTIC ANEURYSM (AAA) SCREENING Note: To be covered, referral must have been as a result of the Initial Preventive Physical Examination (IPPE) AAA screening not covered when referral is a result of the annual or subsequent Annual Wellness Visit 31 Updates, Reminders, and Resources 32 PALMETTO GBA ADVANCED CLINICAL EDITING SYSTEM (P-ACE) COMING THIS FALL! Proactive strategy involves enabling your staff to edit problem areas of a claim well in advance of it being submitted No downloads or software is required! Integrate with whatever clearinghouse/billing service you currently use P-ACE will mean faster, higherquality and increased first pass rate adjudication of claims. It will help improve cash flow and reduce days in accounts receivables due to fewer denied claims 33 11

12 CMS ROAD TO 10 WEBCAST SERIES (ICD-10) Aimed at helping small practices get ready for ICD- 10 by the October 1, 2015, compliance date. Introducing the Road to 10 Training and Preparation on the Road to 10 Clinical Documentation and Coding on the Road to REPORTING THE SERVICE LOCATION NATIONAL PROVIDER IDENTIFIER (NPI) ON ANTI-MARKUP AND REFERENCE LABORATORY CLAIMS Effective January 1, 2015 When billing for reference laboratory services, or services subject anti-markup Report the NPI of the physician or supplier who actually performed the service in Item 32a of the CMS-1500 claim form or the corresponding electronic equivalent (also include supplier name, address and zip code. Anti-mark up claims identified by the presence of the Yes indicator in Item 20 of the CMS-1500 or its electronic equivalent. Reference laboratory claims identified by the presence of modifier 90 on any service line. MM INFLUENZA AND PNEUMOCOCCAL ROSTER BILLING FOR MASS IMMUNIZERS Mass Immunizer Generally offers flu and/or pneumonia (PPV) vaccinations to a large number of individuals (the general public or members of a specific group, such as residents of a retirement community) May be a traditional Medicare provider/supplier or may be a nontraditional provider/supplier such as a senior citizen s center, a public health clinic, community pharmacy or supermarket A mass immunizer submits claims for immunizations on roster bills Mass immunizers MUST accept assignment Instruction packet contains instructions on how to submit claims using the roster billing method B~Browse%20by%20Topic~Preventive%20Services~Immunization~Influenza%20and%20P neumococcal%20roster%20billing%20packet%20and%20forms 36 12

13 CHANGES TO PROVIDER SPECIALTY CODES Effective January 1, 2015 New physician specialty code for Interventional Cardiology C3 Removes word clinical from the description of specialty 62 to Psychologist (billing independently) Changes description of specialty code 88 to Unknown Provider Changes description of specialty code 95 to Unknown Supplier 37 MM8812 CERT-NATIONAL VS. JURISDICTIONAL ERRORS 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 9.9% 14.6% 10.5% 12.7% National Part B CERT Error Rate J11 Part B CERT Error Rate 0.0% CERT SKILLED NURSING FACILITY (SNF) CERTIFICATIONS AND RECERTIFICATIONS Major source of improper payments stems from SNFs failure to obtain certification and recertification statements from physicians or NPPs Routine admission order established by a physician is not a certification of the necessity for post hospital extended care services for purposes of the program CMS Special Edition MLN Matters Article outlines acceptable certification statement content. 39 SE

14 PROJECTED ERROR RATE J11 Part B Total Projected Dollar Loss $887,432,973 Advanced imaging $18,224,750 Other drugs $49,967,305 Hospital visit - subseq. $61,024,241 Office visits - estab. $111,084,272 Lab tests $205,543, SELF SERVICE TOOLS 41 ONLINE PROVIDER SERVICE (OPS) Free access! eforms (eoffset, echeck) eclaims Appeals Remittances Eligibility Claims Status Information (payment floor and last three checks) 42 14

15 EDUCATIONAL RESOURCES Gateway to customized learning! Medicare Advisory and Articles Frequently Asked Questions (FAQs) Ask the Contractor Teleconference (ACT) Listserv Updates Workshops and teleconferences Live Webcasts Self-paced learning Join the conversation! Going Beyond Diagnosis Blog Palmetto GBA and Provider DMAIC activities are posted on GBD blog 43 HELPFUL LINKS List of Resources Palmetto GBA Listserv Website Contact Us Palmetto GBA J11 Part B Home Page Provider Enrollment Resources Select updates Click on the Browse by Topic then select Provider Enrollment 44 SOCIAL NETWORKING 45 15

16 TIME FOR QUESTIONS Thank you for attending

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