By Cyber Sense Billing Team · Published · Updated
Two different preventive systems
Family practices see patients across every age and coverage type, and the rules for preventive visits differ sharply between Medicare and most commercial plans. Commercial plans typically cover an annual preventive physical reported with the CPT preventive medicine codes 99381–99397, which are selected by patient age and new or established status. Medicare does not cover a routine annual physical. Instead, it covers a one-time Initial Preventive Physical Examination and Annual Wellness Visits, each with its own HCPCS codes and required elements. Billing a Medicare patient's yearly checkup with a commercial preventive code is one of the most common primary care billing errors.
Medicare's Initial Preventive Physical Examination
The IPPE, sometimes called the Welcome to Medicare visit, is reported with G0402 and is available once within the first 12 months after a patient's Part B coverage begins. It includes a review of medical and social history, a review of risk factors for depression and functional ability, measurement of height, weight, BMI, blood pressure, and visual acuity, end-of-life planning upon agreement, education and referral for other preventive services, and an optional screening ECG reported separately. Part B deductible and coinsurance generally do not apply to the IPPE.
Medicare Annual Wellness Visits
After the first 12 months of Part B, patients may receive an initial Annual Wellness Visit, G0438, and then subsequent AWVs, G0439, once every 12 months. The AWV centers on a health risk assessment and a personalized prevention plan, including a review of medical and family history, list of providers, cognitive assessment, depression risk review, functional ability review, and a written screening schedule. It does not include a comprehensive physical exam. Patients who expect a head-to-toe physical should be told in advance what the visit includes.
Commercial plans and ACA preventive coverage
Under the Affordable Care Act, most non-grandfathered commercial plans must cover certain preventive services without cost sharing when delivered in network. These include services with an A or B recommendation from the US Preventive Services Task Force, recommended immunizations, and preventive care for women and children under specific guidelines. Plans usually cover one preventive physical per year, though some count by calendar year and others by 365 days, a difference that causes denials when patients schedule visits early. Verify the frequency rule for each plan.
When a problem is addressed during a preventive visit
Both Medicare and commercial plans allow a separate problem-oriented E/M when a significant, separately identifiable problem is addressed during a preventive visit, reported with modifier 25. Patients may owe cost sharing for that problem visit even though the preventive service is free, which often surprises them. A brief notice at check-in explaining that discussing new or chronic problems may result in a separate charge reduces complaints and supports transparent billing.
Medicare patients who request a physical
Some Medicare patients ask for a traditional physical anyway. Practices may offer the 99381–99397 preventive medicine service as a noncovered service, with the patient responsible for payment. Medicare does not require an ABN for statutorily excluded services, though many practices provide a voluntary notice so patients understand the cost before the visit. Medicare Advantage plans may cover an annual physical as a supplemental benefit, so check the patient's specific plan.
Building the right visit at scheduling
Most preventive visit errors start at scheduling. Train schedulers to ask about coverage type and the date of the last preventive visit, to book Medicare patients for an IPPE or AWV rather than a physical, and to note whether the patient also wants to discuss specific problems. Visit templates can then match the visit type, prompting staff for the health risk assessment in AWVs and age-appropriate counseling in commercial preventive visits. Running a monthly report of preventive denials by reason highlights where scheduling or coding needs attention.
Frequently asked questions
What code is used for a Medicare screening ECG with the IPPE?
The optional screening ECG associated with the IPPE has its own HCPCS codes and is reported separately. Confirm the current code set in CMS preventive services guidance.
Are preventive labs free for commercial patients?
Only services that fall within the plan's preventive coverage, such as certain recommended screenings, are covered without cost sharing in network. Labs ordered to monitor existing conditions are usually subject to normal cost sharing, even if drawn during a preventive visit.
Can an AWV and a problem visit be billed on the same day?
Yes. When a significant, separately identifiable problem is addressed, an E/M with modifier 25 may be billed with the AWV. The patient may owe cost sharing for the problem visit, so explain that in advance.
Can we bill an AWV and an IPPE in the same year?
No. The IPPE is available in the first 12 months of Part B, and the initial AWV is available only after that period and at least 12 months after an IPPE.
Does Medicare cover a yearly physical exam?
Traditional Medicare does not cover a routine physical. It covers the IPPE and Annual Wellness Visits. Some Medicare Advantage plans add a physical benefit.
Why did a commercial plan deny an annual physical?
Common reasons include a frequency rule based on 365 days, an out-of-network provider, or a plan that is grandfathered and not subject to ACA preventive rules.
Sources and further reading
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This article is general information, not legal or coding advice. Always check current CPT®, ICD-10-CM, CMS and payer guidance. Questions? Contact us.