Coding and Informatics

Coding and Informatics

When is the GE modifier used in outpatient clinic?

A. When an attending physician sees a patient by herself

B. When a resident physician sees a patient by herself

C. When an attending physician sees a patient with the resident

D. For a nurse visit without a physician seeing the patient

Answer: B

The GE modifier is used when a resident sees a patient by herself. The GC modifier is used when an attending physician sees a patient with the resident. The GC and GE modifiers are not used when an attending physician sees a patient by themselves. A nurse visit does not use either the GE or GC modifier.

Reference: Centers for Medicare and Medicaid Services. Physicians/Nonphysician Practitioners. In, CMS, Medicare Claims Processing Manual. Baltimore, MD: CMS; 2017:166. CMS website. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed April 1, 2020.

How often can a Medicare beneficiary receive the Initial Preventive Physical Examination (IPPE)?

A. One time within the first 12 months of the beginning of Medicare Part B coverage

B. Every 12 months

C. One time after the first 12 months of the beginning of Medicare Part B coverage

D. As often as needed to manage chronic health problems

Answer: A

The Initial Preventive Physical Exam (IPPE, also called the "Welcome to Medicare" exam) can only be billed one time per Medicare beneficiary (G0402) within the first 12 months of the start of their Medicare Part B coverage and has strict criteria that must be fulfilled in order for it to be reimbursed. If the patient is outside of the initial 12-month window, they can still have this preventative service but it is billed as an Annual Wellness Visit (AWV) with PPPS (personalized prevention plan services) and is billed as G0438 (AWV, including PPPS, first visit). After either the IPPE or an initial AWV (patient must have one or the other) then the Annual Wellness Visit is billed as G0439 (AWV, including PPPS, subsequent visit). Visits for chronic health problems are billed as Evaluation and Management (E/M) visits.

Reference: Physicians/Nonphysician Practitioners. In: Centers for Medicare and Medicaid Services. CMS, Medicare Claims Processing Manual. Baltimore, MD: CMS; 2017:40-41. CMS website. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed April 1, 2020.

When is a 25 modifier used in the outpatient clinic?

A. For a significant, separately ...