[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR410.16]



[Page 320-321]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 410_SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS--Table of Contents

 

               Subpart B_Medical and Other Health Services

 

Sec. 410.16  Initial preventive physical examination: Conditions for 

and limitations on coverage.



    (a) Definitions. As used in this section, the following definitions 

apply:

    Eligible beneficiary means an individual who receives his or her 

initial preventive physical examination within 6 months after the 

effective date of his or her first Medicare Part B coverage period, but 

only if that first Part B coverage period begins on or after January 1, 

2005.

    Initial preventive physical examination means all of the following 

services furnished to an eligible beneficiary by a physician or other 

qualified nonphysician practitioner with the goal of health promotion 

and disease detection:

    (1) Review of the beneficiary's medical and social history with 

attention to modifiable risk factors for disease, as those terms are 

defined in this section.

    (2) Review of the beneficiary's potential (risk factors) for 

depression, including current or past experiences with depression or 

other mood disorders, based on the use of an appropriate screening 

instrument for persons without a current diagnosis of depression, which 

the physician or other qualified nonphysician practitioner may select 

from various available standardized screening tests designed for this 

purpose and recognized by national professional medical organizations.

    (3) Review of the beneficiary's functional ability, and level of 

safety as those terms are defined in this section, as described in 

paragraph (4) of this definition, based on the use of appropriate 

screening questions or a screening questionnaire, which the physician or 

other qualified nonphysician practitioner may select from various 

available screening questions or standardized questionnaires designed 

for this purpose and recognized by national professional medical 

organizations.

    (4) An examination to include measurement of the beneficiary's 

height, weight, blood pressure, a visual acuity screen, and other 

factors as deemed appropriate, based on the beneficiary's medical and 

social history, and current clinical standards.

    (5) Performance and interpretation of an electrocardiogram.

    (6) Education, counseling, and referral, as deemed appropriate by 

the physician or qualified nonphysician practitioner, based on the 

results of the review and evaluation services described in this section.

    (7) Education, counseling, and referral, including a brief written 

plan such as a checklist provided to the beneficiary for obtaining the 

appropriate screening and other preventive services that are covered as 

separate Medicare Part B benefits as described in section 1861(s)(10), 

section 1861(jj), section 1861(nn), section 1861(oo), section 1861(pp), 

section 1861(qq)(1), section 1861(rr), section 1861(uu), section 

1861(vv), section 1861(xx)(1), and section 1861(yy) of the Act.

    Medical history is defined to include, at a minimum, the following:

    (1) Past medical and surgical history, including experiences with 

illnesses,



[[Page 321]]



hospital stays, operations, allergies, injuries, and treatments.

    (2) Current medications and supplements, including calcium and 

vitamins.

    (3) Family history, including a review of medical events in the 

beneficiary's family, including diseases that may be hereditary or place 

the individual at risk.

    A physician for purposes of this section means a doctor of medicine 

or osteopathy (as defined in section 1861(r)(1) of the Act).

    A qualified nonphysician practitioner for purposes of this section 

means a physician assistant, nurse practitioner, or clinical nurse 

specialist (as authorized under section 1861(s)(2)((K)(i) and section 

1861(s)(2)((K)(ii) of the Act and defined in section 1861(aa)(5) of the 

Act, or in Sec. 410.74, Sec. 410.75, and Sec. 410.76).

    Review of the beneficiary's functional ability and level of safety 

must include, at a minimum, a review of the following areas:

    (1) Hearing impairment.

    (2) Activities of daily living.

    (3) Falls risk.

    (4) Home safety

    Social history is defined to include, at a minimum, the following:

    (1) History of alcohol, tobacco, and illicit drug use.

    (2) Diet.

    (3) Physical activities.

    (b) Condition for coverage of an initial preventive physical 

examination. Medicare Part B pays for an initial preventive physical 

examination provided to an eligible beneficiary, as described in this 

section, if it is furnished by a physician or other qualified 

nonphysician practitioner, as defined in this section.

    (c) Limitations on coverage of initial preventive physical 

examinations. Payment may not be made for an initial preventive physical 

preventive examination that is performed for an individual who is not an 

eligible beneficiary as described in this section.



[69 FR 66420, Nov. 15, 2004]