[Code of Federal Regulations]
[Title 42, Volume 2]
[Revised as of October 1, 2007]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR410.16]

[Page 326-328]
 
                         TITLE 42--PUBLIC HEALTH
 
                             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

[[Page 327]]

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 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), section 1861(yy), and section 1861(bbb) 
of the Act.
    Medical history is defined to include, at a minimum, the following:
    (1) Past medical and surgical history, including experiences with 
illnesses, 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

[[Page 328]]

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, as amended at 71 FR 69783, Dec. 1, 2006]