The Medicare Annual Wellness Visit (AWV) is a yearly planning appointment designed to help beneficiaries remain healthy by focusing on disease prevention and risk reduction. This fully covered benefit under Medicare Part B creates or updates a personalized prevention plan, reviews existing health risks, and coordinates future care. While the visit is covered 100% when the provider accepts assignment, this coverage applies only to the specific elements included in the AWV itself. This article addresses the services and procedures commonly mistaken for being part of the AWV but are not covered under that benefit.
Hands-On Physical Examination Components
The Annual Wellness Visit is fundamentally a “hands-off” risk assessment and planning session, not a comprehensive physical examination. While the provider measures routine metrics like height, weight, blood pressure, and Body Mass Index (BMI), the AWV excludes detailed, hands-on procedures expected in a traditional yearly physical. This includes checks such as breast or pelvic examinations, prostate checks, or extensive heart and lung auscultation beyond basic screening.
The goal of the AWV is to establish a health baseline and create a five-to-ten-year screening schedule, not to perform a full head-to-toe checkup. If a patient requests or the provider determines a need for these hands-on components, they must be billed separately as an Evaluation and Management (E/M) service. This means the beneficiary may incur a copayment or deductible for the E/M portion of the visit. The two services can be provided during the same encounter but must be documented and billed distinctly.
Diagnostic Lab Work and Imaging
Routine diagnostic testing, such as blood work, urinalysis, X-rays, and other imaging services, is explicitly not included as part of the AWV benefit. The AWV focuses on collecting information through a Health Risk Assessment and reviewing medical history, not on generating new biological data through laboratory analysis. Therefore, common tests like a complete blood count, cholesterol panels, or kidney function tests are not covered under the AWV codes (G0438 or G0439).
Although the AWV does not cover the execution of these tests, it includes creating a personalized prevention plan with a schedule for appropriate, age-specific preventive screenings. The actual performance of these screenings, such as a mammogram, colonoscopy, or drawing blood for a lipid panel, is a separate service. These services are typically covered under Medicare Part B but may be subject to their own coverage rules, copayments, or deductibles distinct from the AWV.
Treatment of Acute or Chronic Illnesses
The Medicare Annual Wellness Visit is strictly for preventive planning and risk assessment, maintaining separation from the active management of existing medical conditions. If a patient presents a new symptom, such as a persistent cough or a rash, or requires significant time to manage a complex chronic condition, that time is not covered by the AWV benefit. The visit must focus on reviewing the patient’s history and planning future care, not diagnosing or treating current problems.
If a patient’s chronic condition, like diabetes or hypertension, requires evaluation and treatment during the same appointment, the provider must bill for the AWV and a separate Evaluation and Management service. This additional service addresses the medical necessity of the treatment, requiring the provider to use a distinct CPT code with a modifier. The cost for this treatment portion is subject to standard Part B deductibles and coinsurance, unlike the AWV.
Routine Care and Statutory Exclusions
Beyond the scope of the AWV, certain categories of routine care are excluded from Original Medicare Part B coverage entirely due to statutory exclusions. These exclusions are common sources of confusion for beneficiaries. Routine dental care, including cleanings, fillings, and dentures, is not covered unless it is medically necessary for a covered service, such as a kidney transplant or jaw surgery.
Similarly, routine vision care, like eye exams for prescribing eyeglasses or contact lenses, is not covered. Medicare does cover eye exams for specific conditions, such as an annual exam for beneficiaries with diabetes or an exam to check for glaucoma in high-risk individuals. Hearing aids and exams for fitting them are also excluded, even though the AWV includes a risk assessment for hearing impairment. Routine foot care is another exclusion, though coverage may be provided if the patient has a medical condition, like diabetic neuropathy, that makes the foot care medically necessary.