What is the purpose of this CBR?
The Centers for Medicare & Medicaid Services (CMS) utilizes CBRs as a tool to educate providers about correct billing procedures. CBR201707 focuses on providers who submitted claims for Initial Preventive Physical Examinations (IPPEs) and Annual Wellness Visits (AWVs) with Healthcare Common Procedure Coding System (HCPCS) codes G0402, G0438 and G0439. For more information about CBRs, please visit our website at this link: Comparative Billing Reports.
Why were IPPEs and AWVs chosen as a topic for a comparative billing report (CBR)?
This topic was selected as a CBR because Medicare spending is increasing for these services since the Affordable Care Act (ACA) has mandated that some preventive visits be provided free of charge.
How were providers selected to receive CBRs?
To choose recipients for this CBR, we analyzed Medicare Part B claims of providers by Rendering NPI who billed HCPCS codes G0402, G0438 and G0439. Approximately 12,000 providers were selected as CBR recipients due to having different billing practices than their peers. If you did not receive a CBR letter and would like to review a sample, please visit our website at CBR201707 Sample CBR.
Did I receive a CBR because of incorrect billing?
Receiving a CBR does not necessarily mean you are billing incorrectly; however, it does indicate that your billing is different than your peers. If you have questions and or concerns about your CBR, please contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.
Is the CBR considered an audit?
The CBR team does not have access to medical records nor do we audit claims. As such, receipt of a CBR is not considered an audit. If interested in resources that may be helpful with setting up a self- audit process, please visit our CBR website page at the link titled Self-Audit Help.
Is the IPPE the same as a Medicare beneficiary’s yearly physical?
No. The IPPE is not a physical checkup that some beneficiaries may get annually. The IPPE (HCPCS code G0402), also known as the Welcome to Medicare Preventive Visit, is a benefit offered once in a lifetime to beneficiaries to introduce them to Medicare. The IPPE focuses on health promotion and disease prevention and detection. Medicare waives both the coinsurance and deductible for this exam. For more information about the IPPE, select this web link: The ABCs of the Initial Preventive Physical Examination (IPPE).
Is the AWV a yearly routine physical that is covered by Medicare?
No. Medicare does not cover routine physical examinations. The initial AWV (HCPCS code G0438) is covered 12 months after the effective date of a beneficiary’s coverage. It is a once-in- a-lifetime benefit, and is covered only for those who have not received an IPPE or AWV within the past 12 months. After the initial AWV, the beneficiary may also have a subsequent AWV annually (HCPCS code G0439). The coinsurance and deductible are waived for both the initial and subsequent AWV. Additional information about the AWV is available at the following link: The ABCs of the Annual Wellness Visit (AWV).
Is the Health Risk Assessment (HRA) required for both the IPPE and the AWV?
The HRA is a component of the AWV. It is not required for the IPPE. The HRA gathers information from the beneficiary for the provider to use to evaluate the health of a patient. The information should include demographics, self- assessment of health, psychosocial/behavioral risks and activities of daily living (ADLs) such as dressing, bathing and walking. The Centers for Disease Control and Prevention (CDC) has a sample HRA in the appendix of the following publication: A Framework for Patient-Centered Health Risk Assessments.
Can any provider perform the IPPE and AWV?
Appropriate providers for both the IPPE and the AWV include physicians (doctors of medicine or osteopathy) or qualified non-physician practitioners (physician assistant, nurse practitioner, certified clinical nurse specialist). In addition, the AWV may be performed by other medical professionals such as health educators, registered dietitians, nutritionists or other licensed practitioners.
Will Medicare pay for laboratory tests performed during the IPPE or AWV?
Laboratory testing is not included in the IPPE and AWV; however, providers may make referrals for these tests, if appropriate. In this case, the deductible and coinsurance would apply.
Can I bill an electrocardiogram (EKG) and the IPPE or AWV on the same date of service?
Generally, other services such as an EKG can be provided on the same date as an AWV or IPPE; however, neither the deductible nor coinsurance/copayment is waived. The following HCPCS codes should be used to file claims for the IPPE and EKG screening:
- G0403 - Electrocardiogram, routine ECG with 12 leads; performed as a screening
- G0404 - Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive
- G0405 - Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination
To review more details, select the following web link: The ABCs of the Initial Preventive Physical Examination (IPPE).
If a beneficiary enrolled in Medicare in 2016, but did not have an IPPE in 2016, is this individual eligible to have an IPPE in 2017?
A beneficiary whose initial enrollment in Medicare Part B began in 2016 is eligible for an IPPE in 2017 as long as it is performed within 12 months of the date the beneficiary’s coverage became effective. Providers should check with their Medicare Administrative Contractor (MAC) to see what options are available to verify beneficiary eligibility. To find your MAC’s contact information, select the following web link: Review Contractor Directory – Interactive Map.
How can I find out whether to bill for an initial or a subsequent AWV if this is the first one that I provided to a beneficiary?
Please contact your MAC to see what options are available to verify beneficiary eligibility. Depending on where you practice, there are different options for accessing AWV eligibility information. You may access the information through the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS) or through the provider call center Interactive Voice Responses (IVRs) operated by your MAC. To find your MAC’s contact information and details on these systems, select the following web links:
- Claim Status Request and Response
- How to Get Connected – HETS 270/271
- Review Contractor Directory – Interactive Map
How can providers help their patients remain up-to-date on preventive services they need?
Providers can offer their patients a Medicare checklist to help them keep track of their upcoming preventive services. The checklist is available at this web link: Are You Up-to-Date on Your Preventive Services?
Where can providers find resources about other preventive services that are covered by Medicare?
CMS offers an interactive website listing the preventive services covered by Medicare. To access that website, select the following web link: Medicare Preventive Services.
How was the data obtained for this report?
Claim lines with the HCPCS codes G0402, G0438 and G0439 were pulled from the Integrated Data Repository (IDR) on July 6, 2017 for Medicare Part B providers. The providers were identified by Rendering NPI as indicated on the claim. The claim lines used in this analysis cover dates of service between April 1, 2016 and March 31, 2017. For more information on the IDR, please visit the link titled, CMS Integrated Data Repository (IDR).
What metrics did you use in this report?
The metrics analyzed in this report are:
- The percentage of services submitted with E/M by HCPCS code
- The average allowed charges for all Medicare Part B services per beneficiary submitted with IPPE/AWV
Why did some providers in our practice receive CBRs and others did not receive one?
After analyzing the data for each individual provider, we chose those providers that were Significantly Higher than their peers in at least one of the metrics described above. Additionally, recipients had at least $15,000 in allowed charges and at least 80 beneficiaries. These thresholds are at or near the 85th percentile of all providers of IPPE and/or AWV, and were chosen to ensure that the providers had sufficient information to compare to the peer groups, and that they could benefit from the educational material supplied in this letter.
What do the comparison outcomes mean?
There are four possible outcomes for the comparisons between the provider and the peer groups:
- Significantly Higher is displayed if the provider’s value is higher than the peer value and the statistical test used confirms significance.
- Higher is displayed if the provider’s value is higher than the peer value, but the statistical test does not confirm significance.
- Does Not Exceed is displayed if the provider’s value is not higher than the peer value.
- N/A (Not applicable) is displayed if the provider does not have sufficient data for comparison.
How are the peers defined?
Providers were identified by National Provider Identifier (NPI). The peer groups for comparison with the individual provider are listed below:
- State: All rendering Medicare providers practicing in the provider’s state, with allowed charges for IPPE and/or AWV
- National: All rendering Medicare providers in the nation with allowed charges for IPPE and/or AWV
What does Table 1 show?
Table 1 lists each of the HCPCS Codes with Abbreviated Descriptions covered in this CBR. A sample CBR has been created for a mock provider to give those who did not receive a CBR the opportunity to read the content of the CBR. If you would like to see this example, please select the following link: CBR201707 Sample CBR.
What is the significance of Table 2?
Table 2 is titled Summary of Your Utilization of IPPE/AWV. This table gives a summary of the individual provider’s utilization of each procedure code and includes the HCPCS Code, Allowed Charges, Allowed Services, and Beneficiary Count. To view a sample report, select the following link: CBR201707 Sample CBR.
What is the explanation for Table 3?
Table 3 is the individual provider’s Percentage of Services Submitted with E/M by HCPCS Code. An E/M service may be billed with the IPPE/AWV code only if a significant, separately identifiable, medically necessary problem is addressed during the visit. This metric is a comparison of the percentage of services that you submitted with an E/M as compared to your peers.
In the CBR201707 Sample CBR, for HCPCS code G0438, the mock provider has 93 services submitted with E/M services out of a total of 96 services for this code. Table 3 shows that this provider’s value of 97 percent is Significantly Higher than both the state’s 32 percent and the nation’s 41 percent. It is important to note here that significance is based on not only the differences between the individual provider’s values and the peer group values, but also the total number of services under analysis and the variability of those values. In this example, even though this provider’s percentage of services submitted with E/M for HCPCS code G0402 is 100 percent (6 out of 6), the statistical test does not show significance because the total number of services is so low. That is why Higher is shown under the comparison with the state and nation for this code, and also for HCPCS code G0439. To see the percentage of services submitted with E/Ms for each state and the nation, please select the CBR web link at CBR201707 Statistical Debriefing.
How are the percentages calculated in Table 3?
This measure is calculated as the Number of Services Submitted with E/M divided by the Total Number of Services. These values are included in Table 3, as well as the state and national percentages.
What is the meaning of Table 4?
Table 4 is the individual provider’s Average Allowed Charges of All Medicare Part B Services per Beneficiary Submitted with each HCPCS Code. In the sample (CBR201707 Sample CBR), the mock provider has a total of 96 beneficiaries and total allowed charges of $31,718.82 for ALL Medicare Part B services that were submitted at the time of the AWV (HCPCS G0438). Since the average charges per beneficiary are $330.40, this mock provider is Significantly Higher than both the state’s average of $303.67 and the national average of $258.54. To view results for each state and the nation, select the following link: CBR201707 Statistical Debriefing.
How are the provider’s average charges per beneficiary calculated in Table 4?
This provider’s average allowed charges are calculated as the Total Charges Allowed for All Part B Services at IPPE/AWV divided by the Total Number of Beneficiaries. These values are included in Table 4, as well as the provider’s calculated averages. To see the mock provider’s example, select this CBR link: CBR201707 Sample CBR.