How do I determine the last date a patient got a preventive service so I know they’re eligible to get the next service and it won’t deny because of frequency edits?

Learn how to check eligibility. You may access eligibility information through the CMS HIPAA Eligibility Transaction System (HETS) either directly or through your:

• Eligibility services provider
• Medicare Administrative Contractor (MAC) provider web portal

Contact your eligibility services provider or find your MAC’s website.

My patients don’t follow up on routine preventive care. How can I help them remember when they’re due for their next preventive service?

We offer a preventive services checklist so they can track their preventive services.

When can CMS add new Medicare preventive services?

We may add preventive services coverage through the National Coverage Determination (NCD) process if the service is:

• Reasonable and necessary for preventing or detecting illness or disability in early stages
• U.S. Preventive Services Task Force (USPSTF)-recommended with grade A or B
• Appropriate for people entitled to Medicare Part A benefits or enrolled under Medicare Part B

We may also add preventive services through statutory and regulatory authority.

USPSTF Published Recommendations have more preventive services information.

What’s a primary care setting?

We define a primary care setting as a place where clinicians deliver integrated, accessible health care services and are responsible for:

• Addressing most patient health care needs
• Developing a sustained patient partnership
• Practicing in the family and community context

Under this direction, we don’t consider these facilities primary care settings:

• Emergency departments
• Inpatient hospital settings
• Ambulatory surgical centers
• Independent diagnostic testing facilities
• Skilled nursing facilities
• Inpatient rehabilitation facilities
• Hospices

Can I bill the office and outpatient evaluation and management (E/M) visit complexity add-on HCPCS code G2211 with Medicare Part B preventive services?

Starting January 1, 2025, you can report HCPCS code G2211 and E/M services (CPT codes 99202–99205 and 99211–99215) billed with modifier 25 only when performed on the same day as:

• Annual wellness visit (HCPCS codes G0438 and G0439)
• Vaccine administration
• Any Part B preventive service provided in the office or outpatient setting, except glaucoma screenings

We believe that building trust in the longitudinal relationship with your patients is significant when making decisions about their Part B preventive services. We recognize that when preventive services are the primary reason for a visit, you may still address complex medical needs and provide ongoing care coordination. MLN Matters article MM13473 has more information on HCPCS code G2211.