Understanding the Medicare rule
Medicare's Annual Wellness Visit (AWV) follows an 11-full-month rule for subsequent visits, not a 365-day rule. This means that for a subsequent AWV (using billing code G0439), at least 11 full months must have passed since the previous one. This allows you to schedule your visit in the same calendar month as the previous year, though not earlier. For instance, a visit on June 20, 2024, makes you eligible on June 1, 2025.
The initial visit versus subsequent visits
Timing for your first AWV differs. You must have been enrolled in Medicare Part B for at least 12 months. If you had the one-time 'Welcome to Medicare' visit (code G0402), your initial AWV (code G0438) cannot be within 12 months of that visit. If you skipped the 'Welcome to Medicare' visit, your first AWV can be any time after 12 months of Part B coverage. Subsequent AWVs then follow the 11-full-month rule.
What happens during an annual wellness visit?
An AWV is a preventive appointment focused on creating or updating your personalized prevention plan. It differs from a traditional physical exam, which diagnoses and treats current illnesses. An AWV aims to help you stay healthy.
Key components of an AWV include:
- Health Risk Assessment (HRA): A questionnaire to identify health risks.
- Review of History: Medical and family history review.
- Routine Measurements: Height, weight, BMI, and blood pressure.
- Cognitive Assessment: Screening for cognitive impairment.
- Personalized Prevention Plan: A plan with recommended screenings and services.
- Advanced Care Planning: Discussion of advance directives with consent.
- Referrals: To health education or counseling services.
Annual wellness visit vs. physical exam: a crucial distinction
Confusing an AWV with an annual physical can lead to unexpected costs, as Medicare does not cover routine physicals like AWVs.
What to expect during an AWV
- Focus: Prevention and health risk assessment.
- Coverage: 100% covered under Medicare Part B (with accepting provider).
- Exams: Routine measurements only.
- Purpose: To create a personalized prevention plan.
- Billable Services: Addressing medical issues may be billed separately.
What to expect during a physical exam
- Focus: Diagnosis and treatment of current health issues.
- Coverage: Not covered by Original Medicare; patient pays 100%.
- Exams: Comprehensive, hands-on physical.
- Purpose: To diagnose and address symptoms.
- Billable Services: All services, including labs, are subject to deductibles and coinsurance.
Comparison Table: Annual Wellness Visit vs. Annual Physical
| Feature | Annual Wellness Visit (AWV) | Annual Physical Exam |
|---|---|---|
| Primary Focus | Preventive care and health planning | Diagnosing and treating existing health issues |
| Medicare Coverage | Yes, 100% covered under Part B (no deductible/copay) | No, generally not covered by Original Medicare |
| Physical Examination | Routine measurements only (height, weight, blood pressure) | Hands-on, comprehensive physical assessment |
| Included Labs/Tests | No, but referrals are made for appropriate screenings | Yes, may include blood tests and other labs |
| Addressing New Concerns | Requires a separate, billable office visit (subject to cost-sharing) | Included as part of the exam |
| Outcome | Personalized prevention plan and screening schedule | Diagnosis, treatment plan, and prescription management |
Maximizing your annual wellness benefit
To make the most of your AWV and avoid unexpected costs, understand its purpose. When scheduling, clearly state you want an 'Annual Wellness Visit'. Your provider should use the correct billing code (G0439 for subsequent visits).
For new or existing health concerns, schedule a separate appointment. Discussing them during your AWV might lead to separate billing for an evaluation and management service, potentially resulting in a copayment or deductible. Keeping the AWV focused on preventive planning ensures Medicare covers all its benefits.
For detailed information, consult the official Centers for Medicare & Medicaid Services website regarding preventive services, including the AWV. Understanding these specifics helps manage your health and finances. The MLN6775421 – Medicare Wellness Visits guide offers an overview of billing and requirements.
Conclusion
In conclusion, while annual wellness visits are yearly, they need to be 11 full months apart for Medicare coverage, not exactly one year. Knowing these rules and the distinction between an AWV and a physical exam helps beneficiaries effectively use this preventive care tool, maximizing Medicare benefits and managing long-term health.
