Preventive Care Office Visits - Medicare
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Defines coverage for Medicare preventive office visits (Initial Preventive Physical Exam 'Welcome to Medicare', Annual Wellness Visit, annual physical exam) and related optional services for Aspirus Arise members with Medicare Part B.
No material clinical or coverage changes in this revision.
Coverage Criteria
Covered Preventive Visit Types
Covered when the stated timing and visit definitions are met.
One-time EKG screening is covered if ordered as part of the Welcome to Medicare visit. Additional laboratory or diagnostic testing ordered during the visit may be billed under the appropriate benefit and member cost share may apply.
AWV cannot take place within 12 months of the Welcome to Medicare (IPPE). Advanced care planning may be provided as an optional AWV element annually. Additional laboratory or diagnostic testing ordered during the AWV may be billed under the appropriate benefit and member cost share may apply.
Does not include laboratory or diagnostic tests as preventive (e.g., x-rays, blood tests, MRIs). Additional testing ordered may be medically necessary and billed appropriately; member cost share may apply.
Diagnostic laboratory tests, x-rays, or other diagnostic procedures that are ordered or performed during an Initial Preventive Physical Exam (IPPE / 'Welcome to Medicare') or an Annual Wellness Visit (AWV) are not covered as preventive services. These items may be ordered during the visit if medically necessary, but they will be billed and adjudicated under the appropriate benefit (not the preventive benefit) and member cost share may apply.
Coding and Timing
| No codes listed |
Provider Actions and Billing Notes
Prior Authorization — diagnostic/ancillary testing ordered during preventive visits
Prior authorization is not required for Medicare preventive visits (Initial Preventive Physical Exam/IPPE, Annual Wellness Visit/AWV, or annual physical exam). However, any diagnostic laboratory tests, x-rays, EKGs beyond the preventive visit scope may be ordered as medically necessary and will be processed under the most appropriate benefit; prior authorization rules for those diagnostic or therapeutic services (if any) still apply. Verify prior authorization requirements for specific diagnostic or ancillary services before ordering when indicated.
- IPPE (Welcome to Medicare) covered once within first 12 months of Part B enrollment; EKG may be covered if ordered as part of the IPPE — diagnostic services ordered during IPPE may follow separate PA rules.
- AWV covered once every 12 months and cannot take place within 12 months of the IPPE; diagnostic services ordered during AWV may require separate authorization or result in member cost share.
- Annual physical exam covered once per calendar year; labs and diagnostic tests ordered during the visit are not considered preventive and may be billed separately.
Visit type and timing documentation
Document clearly in the medical record whether the visit is the one-time IPPE (within first 12 months of Part B), an AWV (and whether it is initial or subsequent), or an annual physical exam. Record dates of Medicare Part B enrollment and prior IPPE/AWV to demonstrate timing and eligibility. When diagnostic testing is ordered during a preventive visit, note the medical necessity and whether the test is being billed as diagnostic rather than preventive.
- Record IPPE status within the first 12 months of Medicare Part B enrollment.
- Ensure AWV is at least 12 months after any IPPE and document initial vs subsequent AWV.
- If diagnostic tests are ordered, document the reason and indicate separate billing if not preventive.
Out‑of‑scope testing during preventive visit — billing and coverage
Services beyond the preventive scope (for example, diagnostic labs, x-rays, imaging, or other tests) performed or ordered during a preventive visit are not automatically covered as preventive care. These out-of-scope services may incur member cost share and/or require separate billing, coding, or prior authorization according to their benefit category.
- Diagnostic laboratory tests, x-rays, and other tests ordered during IPPE, AWV, or annual physical exam are not covered as preventive and may be subject to cost share.
- Order and bill out-of-scope tests separately from the preventive visit; include documentation of medical necessity when billed as diagnostic.
- Confirm benefit rules and prior authorization requirements for the specific diagnostic/ancillary service before ordering when applicable.
(Provider action) Scheduling and office workflow
When scheduling, inform the patient's office whether the appointment is for the Welcome to Medicare (IPPE) visit, an Annual Wellness Visit, or an annual physical so the correct visit type is captured and appropriate timing rules are applied. Ensure staff understand that ordering any additional diagnostic testing may change billing and benefit application.
- Advise patients to identify the visit type at appointment scheduling to ensure proper coding and timing.
- Train office staff to separate preventive visit services from diagnostic/ancillary orders for billing and authorization purposes.
Definitions
Background
Medicare preventive visits are designed to support risk assessment, prevention counseling, functional assessment and referrals rather than diagnostic evaluation. The IPPE ('Welcome to Medicare') is a face-to-face visit for new Part B beneficiaries within their first 12 months that includes a health review, education/counseling about needed preventive services, and referrals. The AWV provides a personalized prevention plan of services and is covered once every 12 months (and may not occur within 12 months of the IPPE). Advanced Care Planning may be provided as an optional element of the AWV. When additional laboratory or diagnostic testing is clinically indicated during these visits, those tests are ordered as medically necessary and billed under the appropriate benefit with possible member cost sharing.
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