The Medicare Annual Wellness Visit (AWV) is a preventive service designed to develop or update a personalized prevention plan. This appointment is a strategic planning session focused on long-term health and risk reduction, not a hands-on diagnostic checkup. While fully covered by Medicare Part B without a copayment or deductible, the AWV is frequently misunderstood as a comprehensive annual physical exam. Recognizing what this benefit does not cover is important for patients to avoid unexpected costs and to ensure they receive all the necessary types of care.
The Absence of a Head-to-Toe Physical Exam
The most common misconception is that the Annual Wellness Visit is equivalent to a traditional, comprehensive physical examination. Medicare policy explicitly states that the AWV is not a routine physical exam, which is a service generally not covered by the program. The core purpose of the AWV is to review health risks and create a future prevention roadmap, not to perform a detailed physical assessment.
While the visit typically includes routine measurements like height, weight, body mass index (BMI), and blood pressure, it excludes hands-on diagnostic procedures. The AWV does not cover components such as a full neurological exam, deep palpation of the abdomen, detailed skin checks, or testing of reflexes. A traditional physical focuses on a hands-on, head-to-toe evaluation, while the AWV is centered on conversation and standardized assessments, including a Health Risk Assessment (HRA), cognitive screening, and a review of history.
If a provider performs an extensive, hands-on physical assessment beyond these basic measurements, that portion is considered a non-covered routine physical exam. The patient would be responsible for 100% of the cost for the physical exam component, as it falls outside the scope of the free AWV.
Exclusions for Lab Work and Diagnostic Tests
Routine blood work and comprehensive diagnostic imaging are not included as a covered component of the Annual Wellness Visit. The AWV is designed for planning and assessment, meaning it does not automatically cover the cost of tests like a complete blood count (CBC), a full metabolic panel, or routine cholesterol checks. Similarly, diagnostic procedures such as X-rays, electrocardiograms (EKGs), or mammograms are not part of the AWV benefit.
Although these tests are not free as part of the AWV, many are covered by Medicare under separate preventive or diagnostic benefits. For example, a provider may order a cholesterol panel based on risk factors identified during the AWV, but that lab test is billed separately under its own specific coverage rules. If the lab work is ordered as part of a diagnostic workup for a suspected condition, standard Part B deductibles and copayments will apply.
The AWV does include the creation of a screening schedule, which is a checklist of appropriate preventive services the patient should receive, such as colonoscopies or certain vaccinations. These recommended screenings are covered under specific Medicare benefits and are performed and billed during separate, subsequent appointments. The AWV only covers the planning and referral for these services, not the performance of the tests.
Limits on Treating New or Existing Conditions
The Annual Wellness Visit is strictly a preventive and planning service; it does not cover the time spent diagnosing or treating specific medical problems. If a patient uses the AWV appointment to discuss a new symptom, like a persistent cough or new joint pain, the provider must bill for that problem-focused care separately. This is also true for extensive management of existing chronic conditions, such as a complex medication adjustment for diabetes or a detailed review of recent abnormal test results.
When a provider addresses both the AWV and a medical issue during the same appointment, they must “split the visit” and bill for the problem-focused portion using an Evaluation and Management (E/M) code. This E/M service must be significant and separately identifiable from the AWV components, and it will be billed in addition to the AWV code. Because the E/M portion is considered a treatment service, the patient will be responsible for the standard Medicare Part B deductible and copayment for that specific part of the visit.
The provider must clearly document that the medical management of the condition was separate from the required elements of the AWV to justify billing for both services. This separation ensures the patient receives the preventive benefit while acknowledging that the management of acute or chronic illness is a distinct, billable service. Failure to adhere to this separation can lead to the denial of the AWV claim or the patient receiving a bill for the treatment portion.
Administrative Rules and Out-of-Pocket Costs
One administrative limitation is the frequency rule, which dictates that a patient can only receive a subsequent AWV once every 12 months. Eligibility requires 12 full months to have passed since the last AWV or the one-time “Welcome to Medicare” visit. Billing a day too early results in a denial, enforcing the strict annual cycle for yearly planning.
While the AWV itself is free, any non-covered service performed or ordered during the visit can trigger standard Medicare cost-sharing. This includes the patient’s deductible, copayments, or coinsurance for separate medically necessary services, such as diagnostic lab work or the E/M portion for condition management. If a provider anticipates performing a service Medicare is likely to deny, they should present the patient with an Advance Beneficiary Notice of Noncoverage (ABN). The ABN informs the patient they may be responsible for the cost of the specific service if Medicare does not cover it.