An Annual Wellness Visit (AWV) is a preventive health planning session designed to create or update a personalized prevention plan. This visit focuses on identifying health risks and is primarily a discussion and assessment, not a hands-on physical examination or treatment of existing conditions. These visits are generally free, provided specific conditions are met within the structure of your Medicare insurance. The visit serves as a roadmap for maintaining health and scheduling future appropriate screenings.
Understanding Medicare Coverage for Wellness Visits
The Annual Wellness Visit (AWV) is a specific benefit provided under Medicare Part B, which covers certain doctor services and outpatient care. For this preventive service, Medicare waives both the Part B deductible and any co-payments. This means the visit itself costs the beneficiary nothing out-of-pocket when received from a participating provider, provided the service is billed correctly under the Medicare benefit structure.
A beneficiary is eligible for the one-time “Welcome to Medicare” Preventive Visit (billed with code G0402) within the first 12 months of enrolling in Medicare Part B. Following that initial period, beneficiaries become eligible for the Annual Wellness Visit. The first AWV is billed using the code G0438, and subsequent yearly visits are billed with G0439, provided 12 full months have passed since the previous one.
The Difference Between a Wellness Visit and a Physical Exam
The primary source of unexpected charges stems from the confusion between a Medicare Annual Wellness Visit (AWV) and a comprehensive Annual Physical Exam (APE). The AWV focuses on preventive planning, involving a review of medical history, risk factor calculation, routine measurements like height and weight, and developing a personalized care plan for the next five to ten years.
Conversely, an Annual Physical Exam (APE) is a more extensive, hands-on assessment that includes a head-to-toe physical examination and often involves ordering diagnostic tests. Medicare does not cover a routine APE for adults, as it is considered a diagnostic service subject to the Part B deductible and co-payments.
When a patient asks the provider to perform a hands-on physical exam or address a new or existing symptom during the AWV, the visit is often re-coded. Providers frequently combine the free AWV with a billable diagnostic office visit on the same day. This dual billing separates the free preventive planning from the billable diagnostic services, leading to unexpected charges.
Services That May Incur Additional Costs
While the Annual Wellness Visit itself is covered at 100% by Medicare, certain actions taken during the appointment can convert the visit into a billable service. If a patient uses the time to address a new or existing health problem, such as discussing a rash, treating a migraine, or receiving a prescription adjustment, the provider must code this as a separate diagnostic service. This treatment of a specific medical issue is not part of the AWV’s preventive scope and falls under standard Part B coverage rules, which involve deductibles and co-payments.
Furthermore, services like blood work, X-rays, or an electrocardiogram (EKG) are not included in the AWV benefit, even if they are standard components of a traditional physical exam. These diagnostic tests are subject to the Part B deductible and co-insurance, though Medicare may cover them separately if deemed medically necessary. The AWV is strictly a planning session, and any service that moves beyond prevention into diagnosis or treatment will likely incur a separate charge.