To the Editor:

In “How to Conduct a ‘Welcome to Medicare’ Visit” [April 2005], Dr. Randall Card writes: “This should be an extremely focused physical exam. Height, weight, blood pressure, and visual acuity are the only required components. No specific vision tests are mandated, but using the Snellen chart is appropriate.”

The family physicians I work with interpreted this as, “We only have to perform these vital signs during the initial preventive physical exam (IPPE), and no additional examination is necessary.”

According to the Centers for Medicare & Medicaid Services Medicare Claims Processing Manual, [see http://www.cms.hhs.gov/manuals/104_claims/clm104c18.pdf, Section 80], the exam should include “measurement of the individual's height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate by the physician or qualified non-physician provider, based on the individual's medical and social history and current clinical standards.”

Unless I have been living in a vacuum, current clinical standards for preventive physical exams require more than just vital signs. If the patient's medical, family and social histories warrant it, examination of additional organ systems may be necessary.

Author's response:

Ms. Newby raises a great point. One of the main challenges of the IPPE is that it tries to be nonprescriptive in a prescriptive fashion, which makes it confusing. While physicians always have the option of performing an extensive physical exam, we need to remember the IPPE's primary goal is to increase the number of patients who receive Medicare's covered preventive services. Clinicians will always need to use their judgment in assessing the patients' needs and determining what the exam ought to include.

The time required to educate and counsel patients about the risks and benefits of vaccines, screenings and other tests is extensive, and reimbursement for the visit is equal to that of a level 3 new-patient office visit. For these reasons, our office is telling physicians to minimize the time spent performing the physical exam and maximize the time devoted to educating and counseling.