Special CME Issue - West Virginia State Medical Association

homosexual men, and residents
of institutions for the mentally
handicapped). Neither hepatitis
A nor hepatitis B vaccinations
are generally recommended for
routine use in adults in the absence
of high-risk indications. 15
Somewhat surprisingly, tetanus
vaccination was not routinely
covered by Medicare even though it
has long been recommended every
10 years for all persons of all ages
after an initial primary series usually
given in childhood. Patients should
be made aware that they may have
to pay for routine tetanus boosters
out of pocket, however, tetanus
vaccination, when administered as
part of treatment for an injury or
potential exposure, should always
be covered by insurance. Since
2008, tetanus immunization should
be covered under Medicare Part
D when not covered by Part B.
Tetanus-diphtheria (Td) combined
vaccine is usually recommended for
adult booster vaccination and as a
primary series for those who have
not been previously vaccinated.
The newer Tdap vaccine (tetanus,
diphtheria and acellular pertussis)
is also now approved for adults
65 and over in substitution for
one booster or primary series
dose if not received before. 15
In October 2006, the CDC’s
Advisory Committee on
Immunization Practices (ACIP)
recommended all adults over 60
receive one dose of the new shingles
(herpes zoster) vaccine (Zostavax)
and the FDA has since approved the
vaccine for adults over 50 as well. 16
This vaccination is more than 60%
effective in preventing shingles
and post-herpetic neuralgia and is
thus quite worthy of consideration,
though under used because of the
somewhat confusing coverage. This
vaccine, which costs about $150-200,
is not covered by Medicare Part B
but rather by Part D Prescription
Drug Plans (PDP’s) which reimburse
pharmacies rather than physicians.
Exact costs/copays must be verified
by the pharmacy with each patient’s
individual plan. Physicians may
purchase and store the vaccine
(which must be frozen until used),
then bill the managed care plan if
covered or bill the patient, who then
can try to get reimbursed by the PDP.
Alternatively, physicians may give
the patient a prescription to obtain
the vaccine from a pharmacy, which
itself may then bill the patient or be
reimbursed by the PDP. The vaccine
then will have to be delivered to the
physician’s office for administration,
unless able to be given directly by a
qualified nurse or pharmacist directly
in the pharmacy. Although Medicare
Part B does not pay for the vaccine
itself, an administration fee may be
charged if injected in the physician’s
office or clinic. Other than the tetanus
and zoster exceptions discussed,
all the other aforementioned
vaccines continue to be covered
by Medicare Part B as in the past.
Non-Medicare insurance plans may
have their own varying rules.
The complete current list
of recommendations for adult
vaccinations may always be
found on the following web site:
http://www.cdc.gov/vaccines/
recs/schedules/adult-schedule.
htm#print. The Annals of Internal
Medicine also publishes the latest
CDC vaccination guidelines yearly. 15
Initial and Annual “Physicals”
In addition to the aforementioned
specific screenings and vaccinations,
Medicare Part B now covers two new
types of routine physicals, though
these are considerably different
than the “annual physical” typically
conducted by physicians. Other than
the Initial Preventive Physical and
Annual Wellness Visit Medicare
covers no other periodic or routine
examinations (i.e. those provided
in the absence of symptoms).
The Initial Preventive Physical
Examination (IPPE, also known as
the “Welcome to Medicare” exam),
was established in 2005 subsequent
to the Medicare Modernization Act
of 2003. This optional exam, covered
only once per beneficiary per lifetime,
must be performed during the first
12 months (formerly 6 months)
of Medicare Part B coverage (i.e.
usually at 65-66 years old). This
exam includes several mandatory
elements: a comprehensive medical
and social history, review of risk
factors for depression, functional
and safety assessment, a focused
physical exam including height,
weight, blood pressure and visual
acuity, and education and counseling
regarding any issues identified in
the previous elements and regarding
other available preventive services
under Medicare. The IPPE may be
performed by a physician or qualified
non-physician practitioner (physician
assistant, nurse practitioner, or
clinical nurse specialist). The
healthcare common procedure coding
system (HCPCS) code G0344 is used
for the IPPE; and code G0366 is
used for an associated ECG tracing,
interpretation, and report (no longer
required but still optionally covered).
Other covered preventive services
listed above, and if appropriate,
other medically necessary evaluation
and management (E/M) services,
may be performed and billed at
the same visit using modifier –25.
Other than the IPPE and Annual
Wellness Visit (see below), routine or
annual physicals are not covered by
Medicare Part B, despite the existence
of an appropriate CPT code 99397
and the need to see patients regularly
to perform all the above mentioned
tests. Due to the numerous specific
requirements of this Initial Preventive
Visit and the Annual Wellness
Visit, it is advisable to use prepared
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