“welcome to medicare” referral checklistsection 611 of the medicare prescription drug,...
TRANSCRIPT
Issued by LVPG Compliance Department Valid 01/01/09
“WELCOME TO MEDICARE” REFERRAL CHECKLIST
Patient Name: ______________________________ Date of Visit: ______________
Medical Record #: ___________________________ DOB: ____________________
Check box
for
Referred
screening
Test Frequency
Influenza Vaccine Administration Once every 12 months
Pneumonia Vaccine Administration Once
Hepatitis B Vaccine Administration Once
Screening Mammography Baseline–Once;
Once every 12 mo
Pap Smear, Pelvic and Breast Exam Once every 12 months – High
risk for cervical CA; Once
every 24 months – Low risk
Prostate Specific Antigen Test Once every 12 months
Screening Digital Rectal Exam Once every 12 months
Colorectal Cancer Screening: Age 50 and over
Fecal Occult Blood Once every 12 months
Flexible Sigmoidoscopy Once every 48 months
Colonoscopy Once every 24 months – High
risk for colorectal CA;
Once every 10 yrs. - not
meeting criteria for being at
high risk
Barium Enema Alternative to Flexible
Sigmoidoscopy or Screening
Colonoscopy
Bone Mass Measurement Once every 24 months
Screening glaucoma exam by
ophthalmologist or optometrist
Once every 12 months
Screening glaucoma exam under direct
supervision of a physician
Once every 12 months
Cardiovascular Screening blood tests Once every five years
Diabetes Screening Twice per year
Diabetes outpatient self-management
training services
Medical nutrition therapy services for
individuals with diabetes or renal disease
Copy to patient’s chart
Signature: _________________________________ Date: ___________
ZUNG SELF-RATING DEPRESSION SCALE
Patient’s Initials
Date of Assessment
Please read each statement and decide how much of the time the statementdescribes how you have been feeling during the past several days.
A little of Some of Good part Most of Make check mark (✓) in appropriate column. the time the time of the time the time
1. I feel down-hearted and blue
2. Morning is when I feel the best
3. I have crying spells or feel like it
4. I have trouble sleeping at night
5. I eat as much as I used to
6. I still enjoy sex
7. I notice that I am losing weight
8. I have trouble with constipation
9. My heart beats faster than usual
10. I get tired for no reason
11. My mind is as clear as it used to be
12. I find it easy to do the things I used to
13. I am restless and can’t keep still
14. I feel hopeful about the future
15. I am more irritable than usual
16. I find it easy to make decisions
17. I feel that I am useful and needed
18. My life is pretty full
19. I feel that others would be better offif I were dead
20. I still enjoy the things I used to do
Adapted from Zung, A self-rating depression scale, Arch Gen Psychiatry, 1965;12:63-70.
Presented as a service by
© 1997 Glaxo Wellcome Inc. All rights reserved. Printed in USA. WEL056R0 February 1997
Glaxo Wellcome Inc.Research Triangle Park, NC 27709Web site: www.glaxowellcome.com
Consult this key for the value (1-4) that correlates with patients’ responses to each statement.
Add up the numbers for a total score. Most people with depression score between 50 and 69. The
highest possible score is 801.
A little of Some of Good part Most of Make check mark (✓) in appropriate column. the time the time of the time the time
1. I feel down-hearted and blue 1 2 3 4
2. Morning is when I feel the best 4 3 2 1
3. I have crying spells or feel like it 1 2 3 4
4. I have trouble sleeping at night 1 2 3 4
5. I eat as much as I used to 4 3 2 1
6. I still enjoy sex 4 3 2 1
7. I notice that I am losing weight 1 2 3 4
8. I have trouble with constipation 1 2 3 4
9. My heart beats faster than usual 1 2 3 4
10. I get tired for no reason 1 2 3 4
11. My mind is as clear as it used to be 4 3 2 1
12. I find it easy to do the things I used to 4 3 2 1
13. I am restless and can’t keep still 1 2 3 4
14. I feel hopeful about the future 4 3 2 1
15. I am more irritable than usual 1 2 3 4
16. I find it easy to make decisions 4 3 2 1
17. I feel that I am useful and needed 4 3 2 1
18. My life is pretty full 4 3 2 1
19. I feel that others would be better off1 2 3 4
if I were dead
20. I still enjoy the things I used to do 4 3 2 1
Adapted from Zung.2
References: 1. Carroll BJ, Fielding JM, Blashki TG. Depression rating scales: a critical review. Arch Gen Psychiatry. 1973; 28:361-366.
2. Zung WWK. A self-rating depression scale. Arch Gen Psychiatry. 1965;12:63-70.
Presented as a service by
© 1997 Glaxo Wellcome Inc. All rights reserved. Printed in USA. WEL365R0 July 1997
Glaxo Wellcome Inc.Research Triangle Park, NC 27709Web site: www.glaxowellcome.com
KEY TO SCORING THE ZUNG SELF-RATING DEPRESSION SCALE
“WELCOME TO MEDICARE” PATIENT QUESTIONNAIRE
Issued by LVPG Compliance Department Valid 01/01/09 Page 1 of 3
Name: _______________________________ MR# _______________ DOB ______________
Visit Date: ____________
Patients: Falls are often due to hazards that are easy to overlook but easy to fix. This checklist will
help you find and fix those hazards in your home. Please review the following information which asks
about hazards found in each room of your home. For each hazard, the checklist tells you how to fix the
problem. Circle Yes or No for every question.
Floors Look at the floor in each room.
Q. When you walk through a room, do you have to walk around furniture? YES / NO
.Ask someone to move the furniture so your path is clear ٱ
Q. Do you have throw rugs on the floor? YES / NO
.Remove the rugs or use double-sided tape or a non-slip backing ٱ
Q. Are papers, magazines, books, shoes, boxes, blankets, towels or other objects on the floor?
YES / NO
.Pick up things that are on the floor. Always keep objects off the floor ٱ
Q. Do you have to walk over or around cords or wires (like cords from lamps, extension cords,
or cords?) YES / NO
Coil or tape cords and wires next to the wall so you can’t trip over them. Have an electrician ٱ
put in another outlet.
Stairs and Steps Look at the stairs you use both inside and outside your home.
Q. Are papers, shoes, books, or other objects on the stairs? YES / NO
.Pick up things on the stairs. Always keep objects off the stairs ٱ
Q. Are some steps broken or uneven? YES / NO
.Fix loose or uneven steps ٱ
Home Safety and Falls risk Assessment
“WELCOME TO MEDICARE” PATIENT QUESTIONNAIRE
Issued by LVPG Compliance Department Valid 01/01/09 Page 2 of 3
Name: _________________________________ MR# _______________ DOB ________
Visit Date: ____________
Q. Are you missing a light over the stairway? YES / NO
.Have a handyman or an electrician put in an overhead light at the top and bottom of the stairs ٱ
Q. Do you have only one light switch for your stairs (only at the top or at the bottom of the
stairs)? YES / NO
Have a handyman or an electrician put in a light switch at the top and bottom of the stairs. You ٱ
can light switches that glow.
Q. Are the handrails loose or broken? YES / NO
Is there a handrail on only one side of the stairs? YES / NO
Fix loose handrails or put in new ones. Make sure handrails are on both sides of the stairs and ٱ
are as long as the stairs?
Q. Is the carpet on the steps loose or torn? YES / NO
Make sure the carpet is firmly attached to every step or remove the carpet and attach non-slip ٱ
rubber treads on the stairs?
Kitchen Look at your kitchen and eating area.
Q. Are the things you use often on high shelves? YES / NO
Move items in your cabinets. Keep things you use often on the lower shelves (about waist ٱ
high).
Q. Is your step stool unsteady? YES / NO
.Get a new, steady step stool with a bar to hold on to. Never use a chair as a step stool ٱ
“WELCOME TO MEDICARE” PATIENT QUESTIONNAIRE
Issued by LVPG Compliance Department Valid 01/01/09 Page 3 of 3
Name: _________________________________ MR# _______________ DOB ____________
Visit Date: ____________
Bedroom Look at all your bedrooms.
Q. Is the light near the bed hard to reach? YES / NO
.Place a lamp close to the bed where it is easy to reach ٱ
Q. Is the path from your bed to the bathroom dark? YES / NO
Put in a night-light so you can see where you’re walking. Some nightlights go on by themselves ٱ
after dark.
Bathroom Look at all your bathrooms.
Q. Is the tub or shower floor slippery? YES / NO
.Put a non-slip rubber mat or self-stick strips on the floor of the tub or shower ٱ
Q. Do you have some support when you get in and out of the tub or up from the toilet?
YES / NO
.Have a handyman or a carpenter put in grab bars next to and inside the tub and next to the toilet ٱ
_____________________________________ ________________________________________ Physician Signature & Date Patient Signature & Date
Dear Patient:
In preparation for your Welcome To Medicare preventive examination
scheduled on ________________________ at ___________ am / pm,
please complete the enclosed forms and bring them with you at the time of
your visit. It is important that your physician have these completed forms
for review during your visit.
Should you have any questions regarding completion of these forms, you
may contact our office at _____________________________.
Sincerely,
Th
e s
um
ma
ry o
f in
form
atio
n p
rese
nte
d in
th
is b
roch
ure
is in
ten
de
d f
or
Me
dic
are
fe
e-f
or-
se
rvic
e p
hysic
ian
s,
pro
vid
ers
, su
pp
liers
, a
nd
oth
er
he
alth
ca
re p
rofe
ssio
na
ls
this
bro
ch
ure
.
TH
E I
NIT
IAL P
REVEN
TIV
E P
HYSIC
AL
EXAM
INATIO
N (
IPPE)
Ove
r th
e p
ast
25
ye
ars
, C
on
gre
ss t
hro
ug
h le
gis
latio
n
ha
s e
xp
an
de
d t
he
nu
mb
er
of
pre
ve
ntive
an
d s
cre
en
ing
Me
dic
are
Pa
rt B
Pro
gra
m.
Se
ctio
n 6
11
of
the
Me
dic
are
Pre
scrip
tio
n D
rug
, Im
pro
ve
me
nt,
an
d M
od
ern
iza
tio
n
Act
(MM
A)
of
20
03
ad
de
d c
ove
rag
e o
f a
on
e-t
ime
in
itia
l
pre
ve
ntive
ph
ysic
al e
xa
min
atio
n (
IPP
E)
(als
o r
efe
rre
d
to a
s t
he
“W
elc
om
e t
o M
ed
ica
re”
ph
ysic
al e
xa
m o
r th
e
he
alth
pro
mo
tio
n a
nd
dis
ea
se
de
tectio
n.
Se
ctio
n 1
01
(b)
of
the
Me
dic
are
Im
pro
ve
me
nt
for
Pa
tie
nts
an
d P
rovid
ers
Act
of
20
08
(M
IPP
A)
pro
vid
es f
or
of
me
asu
rem
en
t o
f b
od
y m
ass in
de
x a
nd
en
d-o
f-lif
e-
pla
nn
ing
, e
xte
nsio
n o
f th
e c
ove
rag
e p
erio
d,
an
d w
aiv
er
of
the
Me
dic
are
Pa
rt B
de
du
ctib
le.
Th
e I
PP
E is a
pre
ve
ntive
eva
lua
tio
n a
nd
ma
na
ge
me
nt
(E/M
) se
rvic
e t
ha
t in
clu
de
s a
ll o
f th
e f
ollo
win
g
co
mp
on
en
ts:
1.
A r
evie
w o
f th
e in
div
idu
al’s
me
dic
al a
nd
so
cia
l h
isto
ry
de
tectio
n
de
pre
ssio
n o
r o
the
r m
oo
d d
iso
rde
rs
3.
A r
evie
w o
f th
e in
div
idu
al’s
fu
nctio
na
l a
bili
ty a
nd
le
ve
l
of
sa
fety
4.
An
exa
min
atio
n t
o in
clu
de
th
e in
div
idu
al’s
he
igh
t,
we
igh
t, b
loo
d p
ressu
re m
ea
su
rem
en
t, v
isu
al a
cu
ity
scre
en
, m
ea
su
rem
en
t o
f b
od
y m
ass in
de
x (
req
uire
d
se
rvic
e e
ffe
ctive
Ja
nu
ary
1,
20
09
), a
nd
oth
er
facto
rs
as d
ee
me
d a
pp
rop
ria
te b
y t
he
exa
min
ing
ph
ysic
ian
or
5.
En
d-o
f-lif
e-p
lan
nin
g.
Effe
ctive
fo
r d
ate
s o
f se
rvic
e o
n
or
aft
er
Ja
nu
ary
1,
20
09
, th
e I
PP
E in
clu
de
s e
nd
-of-
life
co
nse
nt.
En
d-o
f-lif
e p
lan
nin
g is v
erb
al o
r w
ritt
en
dire
ctive
in
th
e c
ase
th
at
an
in
jury
or
illn
ess c
au
se
s
de
cis
ion
s,
an
d
dire
ctive
.
6.
Ed
uca
tio
n,
co
un
se
ling
, a
nd
re
ferr
al b
ase
d o
n
the
re
su
lts o
f th
e r
evie
w a
nd
eva
lua
tio
n s
erv
ice
s
7.
Ed
uca
tio
n,
co
un
se
ling
, a
nd
re
ferr
al [in
clu
din
g a
ind
ivid
ua
l fo
r o
bta
inin
g a
n e
lectr
oca
rdio
gra
m (
EK
G),
as a
pp
rop
ria
te,
an
d t
he
ap
pro
pria
te s
cre
en
ing
s
an
d o
the
r p
reve
ntive
se
rvic
es t
ha
t a
re c
ove
red
as
IMP
OR
TA
NT
CH
AN
GE
: E
ffe
cti
ve
fo
r d
ate
s o
f s
erv
ice
on
or
aft
er
Ja
nu
ary
1,
20
09
, th
e s
cre
en
ing
EK
G i
s
no
lo
ng
er
a r
eq
uir
ed
pa
rt o
f th
e I
PP
E.
It i
s o
pti
on
al
an
d m
ay
be
pe
rfo
rme
d a
s a
re
su
lt o
f a
re
ferr
al
fro
m
an
IP
PE
(a
s p
art
of
the
ed
uc
ati
on
al,
co
un
se
lin
g,
Th
e s
cre
en
ing
EK
G w
ill
be
all
ow
ed
on
ly o
nc
e i
n a
NO
TE
: T
he
IP
PE
do
es n
ot
inclu
de
an
y c
linic
al la
bo
rato
ry
or
ho
sp
ita
l m
ay a
lso
pro
vid
e a
nd
bill
se
pa
rate
ly f
or
the
scre
en
ing
an
d o
the
r p
reve
ntive
se
rvic
es t
ha
t a
re c
urr
en
tly
co
ve
red
an
d p
aid
fo
r b
y M
ed
ica
re P
art
B.
Co
ve
rag
e I
nfo
rma
tio
n
co
ve
rag
e e
ffe
ctive
da
te b
eg
an
on
or
aft
er
Ja
nu
ary
1,
20
05
, a
re c
ove
red
fo
r a
on
e-t
ime
IP
PE
vis
it.
rece
ivin
g a
n I
PP
E h
as b
ee
n e
xte
nd
ed
fro
m 6
mo
nth
s
in t
he
Me
dic
are
Pa
rt B
Pro
gra
m.
wh
ose
in
itia
l e
nro
llme
nt
in M
ed
ica
re P
art
B b
eg
an
in
20
08
will
be
ab
le t
o h
ave
an
IP
PE
in
20
09
, a
s lo
ng
as
en
rollm
en
t e
ffe
ctive
da
te.
ph
ysic
ian
pra
ctitio
ne
r (p
hysic
ian
assis
tan
t, n
urs
e
pra
ctitio
ne
r, o
r clin
ica
l n
urs
e s
pe
cia
list)
.
NO
TE
:
a p
reve
ntive
ph
ysic
al e
xa
m a
nd
is n
ot
a “
rou
tin
e p
hysic
al
pra
ctitio
ne
r. M
ed
ica
re d
oe
s n
ot
pro
vid
e c
ov
era
ge
fo
r
rou
tin
e p
hy
sic
al
ex
am
s.
vis
it b
y s
ug
ge
stin
g t
he
y c
om
e p
rep
are
d w
ith
th
e f
ollo
win
g
info
rma
tio
n:
ca
lciu
m a
nd
vita
min
s –
ho
w o
fte
n a
nd
ho
w m
uch
of
Co
ve
rag
e o
f th
e I
PP
E v
isit is p
rovid
ed
as a
Me
dic
are
1,
20
09
, th
e a
nn
ua
l P
art
B d
ed
uctib
le is w
aiv
ed
fo
r th
e
IPP
E b
ut
the
co
insu
ran
ce
or
co
pa
ym
en
t still
ap
plie
s.
NO
TE
: T
he
MIP
PA
le
gis
latio
n a
dd
ed
a p
rovis
ion
of
“ad
ditio
na
l p
reve
ntive
se
rvic
es”
un
de
r e
du
ca
tio
n,
co
un
se
ling
, a
nd
re
ferr
al se
rvic
es t
o a
llow
fo
r fu
ture
co
ve
red
pre
ve
ntive
se
rvic
es.
Th
ese
pre
ve
ntive
se
rvic
es
ma
y b
e a
dd
ed
in
th
e f
utu
re t
hro
ug
h t
he
Na
tio
na
l
Co
ve
rag
e D
ete
rmin
atio
n (
NC
D)
pro
ce
ss.
ULT
RASO
UN
D S
CREEN
ING
FO
RABD
OM
INAL A
ORTIC
AN
EU
RYSM
S (
AAA)
inclu
de
co
ve
rag
e,
un
de
r M
ed
ica
re P
art
B,
of
a o
ne
-tim
e
on
ly p
reve
ntive
ultra
so
un
d s
cre
en
ing
fo
r th
e e
arly
de
tectio
n o
f a
bd
om
ina
l a
ort
ic a
ne
ury
sm
s (
AA
A)
for
at
refe
rra
l fo
r th
is s
cre
en
ing
se
rvic
e a
s a
re
su
lt o
f th
eir I
PP
E
vis
it.
An
eu
rys
ms
Th
e t
erm
“u
ltra
so
un
d s
cre
en
ing
fo
r a
bd
om
ina
l a
ort
ic
pro
ce
du
res u
sin
g a
lte
rna
tive
te
ch
no
log
ies,
of
by t
he
Ce
nte
rs f
or
Me
dic
are
& M
ed
ica
id S
erv
ice
s
ea
rly d
ete
ctio
n o
f A
AA
; a
nd
the
pro
ce
du
re.
Effective for
serv
ices furn
ished o
n o
r after
January
1, 2007,
Medic
are
will
pay for
a o
ne-t
ime p
reventive u
ltra
sound
follo
win
g c
rite
ria:
scre
en
ing
as a
re
su
lt o
f a
n I
PP
E;
or
su
pp
lier
wh
o is a
uth
orize
d t
o p
rovid
e c
ove
red
ultra
so
un
d d
iag
no
stic s
erv
ice
s;
an
ultra
so
un
d s
cre
en
ing
un
de
r th
e M
ed
ica
re
Pro
gra
m;
an
d
-h
as a
fa
mily
his
tory
of
ab
do
min
al a
ort
ic a
ne
ury
sm
cig
are
tte
s in
his
life
tim
e
by t
he
Se
cre
tary
of
He
alth
an
d H
um
an
Se
rvic
es
thro
ug
h t
he
NC
D p
roce
ss.
NO
TE
:
refe
rra
l fo
r th
e A
AA
ultra
so
un
d s
cre
en
ing
as a
re
su
lt o
f
Co
ve
rag
e o
f th
e u
ltra
so
un
d s
cre
en
ing
fo
r A
AA
is
or
co
pa
ym
en
t a
pp
lies. T
he
re is n
o M
ed
ica
re P
art
B
CARD
IOVASCU
LAR S
CREEN
ING
BLO
OD
TESTS
Se
ctio
n 6
12
of
the
MM
A e
xp
an
de
d p
reve
ntive
se
rvic
es t
o in
clu
de
co
ve
rag
e,
un
de
r M
ed
ica
re P
art
B,
of
ca
rdio
va
scu
lar
scre
en
ing
blo
od
te
sts
fo
r th
e e
arly
de
tectio
n o
f ca
rdio
va
scu
lar
dis
ea
se
or
ab
no
rma
litie
s
Effe
ctive
fo
r se
rvic
es f
urn
ish
ed
on
or
aft
er
Ja
nu
ary
1,
20
05
, M
ed
ica
re p
rovid
es c
ove
rag
e o
f ca
rdio
va
scu
lar
scre
en
ing
blo
od
te
sts
fo
r th
e e
arly d
ete
ctio
n o
f
ca
rdio
va
scu
lar
dis
ea
se
or
ab
no
rma
litie
s a
sso
cia
ted
with
Th
e c
ard
iova
scu
lar
scre
en
ing
blo
od
te
sts
co
ve
red
by
Me
dic
are
in
clu
de
:
NO
TE
:
testin
g.
Oth
er
ca
rdio
va
scu
lar
scre
en
ing
blo
od
te
sts
rem
ain
no
n-c
ove
red
.
Co
ve
rag
e I
nfo
rma
tio
n
Me
dic
are
pro
vid
es c
ove
rag
e o
f ca
rdio
va
scu
lar
scre
en
ing
ye
ars
(i.e
., a
t le
ast
59
mo
nth
s a
fte
r th
e la
st
co
ve
red
scre
en
ing
te
sts
).
Th
e s
cre
en
ing
blo
od
te
sts
mu
st
be
ord
ere
d b
y t
he
ap
pa
ren
t sig
ns o
r sym
pto
ms o
f ca
rdio
va
scu
lar
dis
ea
se
.
Co
ve
rag
e o
f th
e c
ard
iova
scu
lar
scre
en
ing
blo
od
te
sts
co
insu
ran
ce
or
co
pa
ym
en
t a
nd
no
de
du
ctib
le f
or
this
IMP
OR
TA
NT
NO
TE
:
co
ve
red
by M
ed
ica
re is a
sta
nd
alo
ne
bill
ab
le s
erv
ice
se
pa
rate
fro
m t
he
IP
PE
an
d d
oe
s n
ot
ha
ve
to
be
ob
tain
ed
Me
dic
are
Pa
rt B
en
rollm
en
t.
FO
R M
ORE I
NFO
RM
ATIO
N
Th
e C
en
ters
fo
r M
ed
ica
re &
Me
dic
aid
Se
rvic
es (
CM
S)
ha
s d
eve
lop
ed
a v
arie
ty o
f e
du
ca
tio
na
l re
so
urc
es a
s p
art
of
a b
roa
d o
utr
ea
ch
ca
mp
aig
n t
o p
rom
ote
aw
are
ne
ss
an
d in
cre
ase
utiliz
atio
n o
f p
reve
ntive
se
rvic
es c
ove
red
by
Me
dic
are
.
an
d r
eim
bu
rse
me
nt
of
Me
dic
are
-co
ve
red
pre
ve
ntive
se
rvic
es a
nd
scre
en
ing
s,
vis
it h
ttp
://w
ww
.cm
s.h
hs.g
ov/
ML
NP
rod
ucts
/35
_P
reve
ntive
Se
rvic
es.a
sp
#To
pO
fPa
ge
on
the
CM
S w
eb
site
.
MED
ICARE L
EARN
ING
NETW
ORK
pa
ge
at
htt
p:/
/ww
w.c
ms.h
hs.g
ov/M
LN
Ge
nIn
fo o
n t
he
CM
S
we
bsite
.
BEN
EFIC
IARY-R
ELATED
IN
FO
RM
ATIO
N
Me
dic
are
is lo
ca
ted
on
th
e w
eb
at
htt
p:/
/ww
w.m
ed
ica
re.
go
v,
or
mo
re in
form
atio
n c
an
be
ob
tain
ed
by c
alli
ng
ca
ll 1
-87
7-4
86
-20
48
.
Th
is b
roch
ure
wa
s p
rep
are
d a
s a
se
rvic
e t
o t
he
pu
blic
an
d is n
ot
inte
nd
ed
to
gra
nt
sta
tute
s,
reg
ula
tio
ns,
or
oth
er
po
licy m
ate
ria
ls. T
he
in
form
atio
n p
rovid
ed
is o
nly
reg
ula
tio
ns a
nd
oth
er
inte
rpre
tive
ma
teria
ls f
or
a f
ull
an
d a
ccu
rate
sta
tem
en
t o
f
the
ir c
on
ten
ts.
ICN
006433
JAN
UA
RY
2009
Medicare
Preventive
Services
ForPhysicians,Providers,Suppliers,andOtherHealthCareProfessionals
Exp
an
ded
Ben
efi
tsIN
ITIA
L PREVEN
TIVE P
HYS
ICA
L EXA
MIN
ATI
ON
(IP
PE)
ULT
RA
SO
UN
D S
CREEN
ING
FO
R
AB
DO
MIN
AL
AO
RTI
C A
NEU
RYS
MS (
AA
A)
CA
RD
IOVA
SC
ULA
R S
CREEN
ING
BLO
OD
TESTS
Med
icare
Prev
entive
Serv
ices
Quick
Ref
eren
ce In
form
ation:
The
ABC
s of
Pro
viding
the
Init
ial P
reve
ntive
Physical E
xam
inat
ion
Th
e I
nitia
l P
reve
ntive
Ph
ysic
al E
xa
min
atio
n (
IPP
E),
als
o k
no
wn
as t
he
“W
elc
om
e t
o M
ed
ica
re P
hysic
al E
xa
m”
or
the
“W
elc
om
e t
o M
ed
ica
re V
isit,”
is a
pre
ve
ntive
eva
lua
tio
n a
nd
ma
na
ge
me
nt
(E/M
) se
rvic
e. T
he
go
als
of
the
IP
PE
are
he
alth
pro
mo
tio
n a
nd
dis
ea
se
de
tectio
n. A
ll co
mp
on
en
ts o
f th
e I
PP
E m
ust
be
pro
vid
ed
, o
r p
rovid
ed
an
d r
efe
rre
d,
prio
r to
su
bm
ittin
g c
laim
s f
or
the
IP
PE
vis
it.
Co
mp
on
ents
of
the
IPP
E (
as
of
Jan
uary
1,
2009
)
Acq
uir
e P
ati
ent
His
tory
Ele
men
ts
1.R
evie
w o
f In
div
idu
al’s
Med
ical
an
d S
oci
al
His
tory
At
a m
inim
um
, o
bta
in t
he
fo
llow
ing
:
2.R
evie
w o
f In
div
idu
al’s
Po
ten
tial
(Ris
k F
act
ors
) fo
r D
epre
ssio
n
an
d O
ther
Mo
od
Dis
ord
ers
Use
an
y a
pp
rop
ria
te s
cre
en
ing
in
str
um
en
t re
co
gn
ize
d b
y n
atio
na
l p
rofe
ssio
na
l m
ed
ica
l o
rga
niz
atio
ns t
o o
bta
in c
urr
en
t o
r p
ast
exp
erie
nce
s w
ith
de
pre
ssio
n o
r
oth
er
mo
od
dis
ord
ers
3.R
evie
w o
f In
div
idu
al’s
Fu
nct
ion
al
Ab
ilit
y an
d L
evel
of
Safe
ty
Use
an
y a
pp
rop
ria
te s
cre
en
ing
qu
estio
ns o
r sta
nd
ard
ize
d q
ue
stio
nn
aire
s r
eco
gn
ize
d b
y n
atio
na
l p
rofe
ssio
na
l m
ed
ica
l o
rga
niz
atio
ns t
o r
evie
w,
at
a m
inim
um
,
the
fo
llow
ing
are
as:
Beg
in P
hys
ical
Ex
am
inati
on
Ele
men
ts
4.A
Ph
ysic
al
Ex
am
inati
on
Ob
tain
th
e f
ollo
win
g:
5.E
nd
-of-
Lif
e P
lan
nin
gd
ecis
ion
s,
an
d
Co
un
sel
Pati
ent
Ele
men
ts
6.E
du
cati
on
, C
ou
nse
lin
g,
an
d
Ref
erra
l B
ase
d o
n t
he
Pre
vio
us
Fiv
e C
om
po
nen
ts
inclu
de
th
e f
ollo
win
g:
7.E
du
cati
on
, C
ou
nse
lin
g,
an
d
Ref
erra
l fo
r O
ther
Pre
ven
tive
S
ervi
ces
pre
ve
ntive
se
rvic
es.)
Med
icar
e P
art
B P
reve
nti
ve S
ervic
esM
edic
are
Par
t B
Pre
ven
tive
Ser
vic
es
Bo
ne
Ma
ss M
ea
su
rem
en
ts
on
e-t
ime
pre
ve
ntive
ultra
so
un
d s
cre
en
ing
fo
r th
e e
arly d
ete
ctio
n o
f A
AA
s a
s p
art
of
the
ir I
PP
E.
**N
EW
:scre
en
ing
EK
G is n
o lo
ng
er
a r
eq
uire
d p
art
of
the
IP
PE
. It
is o
ptio
na
l a
nd
ma
y
IPP
E H
CP
CS C
od
esB
illin
g C
od
e D
escr
ipto
rs
Me
dic
are
en
rollm
en
t
inte
rpre
tatio
n a
nd
re
po
rt
initia
l p
reve
ntive
ph
ysic
al e
xa
min
atio
n
ph
ysic
al e
xa
min
atio
n
Freq
uent
ly A
sked
Que
stions
ch
ecku
p”
tha
t so
me
se
nio
rs m
ay r
ece
ive
eve
ry y
ea
r o
r tw
o f
rom
th
eir
Wh
o c
an
per
form
th
e IP
PE
?T
he
IP
PE
mu
st
be
fu
rnis
he
d b
y e
ith
er
a p
hysic
ian
(a
do
cto
r o
f m
ed
icin
e o
r
nu
rse
pra
ctitio
ne
r, o
r clin
ica
l n
urs
e s
pe
cia
list)
.
Are
cli
nic
al
lab
ora
tory
tes
ts p
art
of
the
IPP
E?
pro
vid
er
ma
y w
an
t to
ma
ke
re
ferr
als
fo
r su
ch
te
sts
as p
art
of
the
IP
PE
.
Is t
her
e a d
edu
ctib
le o
r co
insu
ran
ce/
cop
aym
ent
for
the
IPP
E?
or
co
pa
ym
en
t still
ap
plie
s. T
he
de
du
ctib
le s
till
ap
plie
s t
o t
he
op
tio
na
l
Can
a s
epara
te E
/M
ser
vice
be
bil
led
at
the
sam
e vi
sit
as
the
IPP
E?
ef fe
ctive
da
te.
Wh
o I
s E
lig
ible
to
Rec
eive
th
e IP
PE
?
Effe
ctive
fo
r d
ate
s o
f se
rvic
e o
n o
r a
fte
r
aft
er
the
effe
ctive
da
te o
f th
eir M
ed
ica
re P
art
B
is a
on
e-t
ime
en
rolle
e.
Pre
pari
ng
Eli
gib
le M
edic
are
Pati
ents
fo
r th
e IP
PE
Vis
it
Pro
vid
ers
ca
n h
elp
elig
ible
Me
dic
are
pa
tie
nts
ge
t re
ad
y f
or
the
ir I
PP
E v
isit b
y e
nco
ura
gin
g
the
m t
o c
om
e p
rep
are
d w
ith
th
e f
ollo
win
g
info
rma
tio
n:
Me
dic
al re
co
rds,
inclu
din
g
imm
un
iza
tio
n r
eco
rds
as p
ossib
le
A f
ull
list
of
me
dic
atio
ns a
nd
su
pp
lem
en
ts,
inclu
din
g c
alc
ium
an
d
vita
min
s–
ho
w o
fte
n a
nd
ho
w m
uch
of
ea
ch
is t
ake
n
Res
ou
rces
htt
p:/
/ww
w.c
ms.h
hs.g
ov/M
LN
Pro
du
cts
/
do
wn
loa
ds/m
ps_
gu
ide
_w
eb
-06
13
05
.pd
f
htt
p:/
/ww
w.c
ms.h
hs.g
ov/m
an
ua
ls/d
ow
nlo
ad
s/
clm
10
4c1
2.p
df
htt
p:/
/ww
w.c
ms.h
hs.g
ov/m
an
ua
ls/d
ow
nlo
ad
s/
clm
10
4c1
8.p
df
– U
pd
ate
to
th
e I
nitia
l P
reve
ntive
Ph
ysic
al
htt
p:/
/ww
w.c
ms.h
hs.g
ov/t
ran
sm
itta
ls/
do
wn
loa
ds/R
16
15
CP.p
df
Th
is q
uic
k r
efe
ren
ce
in
form
atio
n c
ha
rt w
as p
rep
are
d a
s a
se
rvic
e t
o t
he
pu
blic
an
d is n
ot
inte
nd
ed
to
gra
nt
rig
hts
or
imp
ose
ob
liga
tio
ns. T
his
ch
art
ma
y c
on
tain
re
fere
nce
s o
r lin
ks t
o s
tatu
tes,
reg
ula
tio
ns o
r o
the
r in
terp
retive
ma
teria
ls. T
he
in
form
atio
n p
rovid
ed
is o
nly
in
ten
de
d t
o b
e a
Ja
nu
ary
20
09