Description
Claims for HCPCS code G0402- Initial Preventative Physical Examination (IPPE), may not be billed more than 12 months after the effective date of the beneficiary’s first part B coverage, or more than once in a lifetime.
Claims for HCPCS code G0438- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); initial, may not be billed more than once in a lifetime.
Claims for HCPCS code G0439- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); subsequent, may not be billed within 12 months of G0438 or G0439.
Affected Code(s)
G0402, G0438, G0439
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (s)(2)(W)- an initial preventive physical exam
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (s)(2)(FF)- Medical and other health services- personalized prevention plan services
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (ww)- Initial Preventive Physical Examination
5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (hhh)-Annual Wellness Visit
6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
7. 42 CFR §405.929- Post-Payment Review
8. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
9. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
10. 42 CFR §405.986- Good Cause for Reopening
11. 42 CFR §410.15 - Annual Wellness Visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage
12. 42 CFR §410.16-Initial Preventative Physical Examination: Conditions for and limitations on coverage
13. Medicare Benefit Policy Manual- Chapter 15- Covered Medical and Other Health Services, §280.5- Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS)
14. Medicare Claims Processing Manual- Chapter 12- Physicians/Nonphysician Practitioners, §30.6.1.1 Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV]
15. Medicare Claims Processing Manual- Chapter 18- Preventive and Screening Services, §140- Annual Wellness Visit
16. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
17. AMA HCPCS/CPT Codebook