Ask the Contractor Teleconference

February 24, 2005

Topic: New Preventive Services

Questions & Answers

IPPE-The Initial Preventive Physical Examination

Question: Are there specific documentation requirements for an IPPE?

Answer: No, not at this time. Charts should reflect the appropriate procedures and screenings performed at the time of the IPPE.

Question: When billing for the IPPE, along with a screening EKG, is a specific diagnosis required?

Answer: Medicare does not require a specific ICD-9-CM when billing for the IPPE.

Question: Does a diagnosis code need to be billed on the claim?

Answer: Yes, a diagnosis code must be billed on all claim forms.

Question: If a patient has a known medical diagnosis and has an EKG performed, that is billed as a separate and identifiable medically necessary service, can the provider also bill for the IPPE?

Answer: The Screening EKG is a component of the IPPE. Therefore, an EKG screening needs to be performed at the time of the IPPE for an IPPE to be paid.

Question: What is the definition of a visual acuity screen service?

Answer: The visual acuity screening is defined as a performance eye exam with the use of an eye chart.

Question:  What does the term “fall risk” refer to under the review of the individual’s functional ability and level of safety?

Answer: Fall risk refers to the patient’s functional/ambulatory level.

Question: Can a cardiologist read the traces and bill with the appropriate procedure code?

Answer: Yes, if the physician or NPP is not able to read both the exam results and screening EKG, an arrangement may be made to ensure that another physician or entity reads the screening EKG and bills with the appropriate code.

Cardiovascular Screening Blood Tests

Question: Does a provider need to specify the diagnosis code when submitting to a lab?

Answer: Yes, the ordering provider should provide the diagnosis and procedure code or narrative when referring a specimen or patient to a lab, so that the lab can bill the appropriate diagnosis and procedure.

Diabetes Screening Tests

Question: What does the “TS” modifier refer to?

Answer:  It refers to a follow up service. (It will become effective April 1, 2005)

Question: Where should the “TS” modifier be listed on a 1500 claim from?

Answer: It should be listed on the line item with the specific CPT it is referring to.

Question: What documentation needs to be recorded when a provider bills for a diabetes screening test?

Answer:  An office must document why the test was done and if the patient is pre-diabetic along with any risk factors that are present.

posted 3/24/2005