Initial Preventive Physical Examination
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provides coverage under Medicare Part B of an initial preventive physical examination (IPPE), including a screening electrocardiogram (EKG) for new beneficiaries (subject to certain eligibility and other limitations) effective for services furnished on or after January 1, 2005. Payment for an IPPE is allowed no later than six months after the date the beneficiary's first coverage period begins under Medicare Part B.
This physical examination is a once-a-lifetime benefit for a beneficiary and it must be performed within six months after the effective date of the beneficiary's first Part B coverage, but only if such Part B coverage begins on or after January 1, 2005. A physical examination given on January 10, 2005, for example, to a beneficiary whose Medicare Part B was effective initially on December 1, 2004 would not be covered under this benefit. If a beneficiary is first covered by Part B on January 1, 2005, then a physical provided on January 10, 2005 would be covered by this new benefit.
This provision provides for payment for an IPPE examination to be performed in various provider settings by a physician, physician assistant, or nurse practitioner.
The initial examination means all of the following services:
- Review of an individual's medical and social history, with attention to modifiable risk factors for disease detection, including past medical and surgical history, such as experiences with illnesses, hospital stays, operations, allergies, injuries and treatments, current medication and supplements, family history (including diseases that may be hereditary or place the individual at risk), history of alcohol, tobacco, and illicit drug use, diet, and physical activities
- Review of an individual's potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the physician or other qualified NPP may select from various available standardized screening tests designed for this purpose and recognized by national professional medical organizations
- Review of the individual's functional ability and level of safety based on the use of appropriate screening questions or a screening questionnaire, which the physician or other qualified NPP may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations, including, at a minimum, a review of hearing impairment, activities of daily living, falls risk, and home safety
- An examination to include measurement of the individual's height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate by the physician or qualified NPP, based on the individual's medical and social history (refer to service element 1) and current clinical standards
- Performance and interpretation of an EKG
- Education, counseling, and referral as deemed appropriate by the physician or qualified NPP, based on the results of the review and evaluation services described in the previous five elements
- Education, counseling, and referral, including a brief written plan (e.g., a checklist or alternative) provided to the individual for obtaining the appropriate screening and other preventive services, which are covered separately under Medicare Part B. These include: (1) pneumococcal, influenza, and hepatitis B vaccines and their administration; (2) screening mammography; (3) screening pap smear and screening pelvic examinations; (4) prostate cancer screening tests; (5) colorectal cancer screening tests; (6) diabetes outpatient self-management training services; (7) bone mass measurements; (8) screening for glaucoma; (9) medical nutrition therapy for individuals with diabetes or renal disease; (10) cardiovascular screening blood tests; and (11) diabetes screening tests
Diabetes Screening Tests
This coverage is mandated by the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA). Initially, coverage was limited to a fasting plasma glucose test. However, coverage is now provided for the following two screening blood tests:
- Fasting plasma glucose test and
- Post-glucose challenge test (an oral glucose tolerance test with a glucose challenge of 75 grams of glucose for non-pregnant adults, or a two-hour post-glucose challenge test alone)
Any individual with one (1) of the following individual risk factors for diabetes is eligible for this new benefit:
- Hypertension
- Dyslipidemia
- Obesity (with a body mass index greater than or equal to 30 kg/m2) or
- Previous identification of elevated impaired fasting glucose or glucose intolerance
Or, an individual with any two (2) of the following risk factors for diabetes is also eligible for this new benefit:
- Overweight (a body mass index >25, but <30 kg/m2)
- A family history of diabetes
- Age 65 years or older or
- A history of gestational diabetes mellitus or giving birth to a baby weighing > 9 lb
Effective for services performed on or after January 1, 2005, Medicare will pay for diabetes screening tests under the Medicare Clinical Laboratory Fee Schedule. To indicate that the purpose of the test(s) is for diabetes screening, a screening diagnosis code is required in the diagnosis section of the claim:
- Two screening tests per calendar year are covered for individuals diagnosed with pre-diabetes
- One screening test per year is covered for individuals previously tested who were not diagnosed with pre-diabetes, or who have never been tested
Cardiovascular Screening Blood Tests
In accordance with the Medicare Modernization Act (MMA), Medicare coverage is provided for cardiovascular screening blood tests (tests for the early detection of cardiovascular disease or abnormalities associated with an elevated risk for that disease) effective for services performed on or after January 1, 2005.
The MMA permits coverage of tests for cholesterol and other lipid or triglycerides levels for this purpose. Therefore, effective January 1, 2005, coverage is provided for the following:
- Total Cholesterol Test
- Cholesterol Test for High Density Lipoproteins and
- Triglycerides Test
Effective, January 1, 2005, Medicare provides coverage for the cardiovascular screening blood test for beneficiaries every five years (i.e., 59 months after the last covered screening tests.) Medicare has determined that it is not necessary to test more frequently since lipid and cholesterol levels for people often stay fairly consistent beyond age 65.
Medicare Part B covers cardiovascular screening blood tests when ordered by the physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals without apparent signs or symptoms.
The implementation of this new benefit permits Medicare beneficiaries who have not been previously diagnosed with cardiovascular disease to receive cardiovascular screening blood tests for risk factors associated with cardiovascular disease. This includes individuals who have no prior knowledge of heart problems but recognize that their behavior or lifestyle may be at risk because of diet or lack of exercise.
Payment is provided under the Medicare Clinical Laboratory Fee Schedule. There is no deductible or copayment for this benefit.
For more information on coverage, billing and coding see Medlearn Matters Number: MM3411
