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What is Not Covered by a Medicare Annual Wellness Visit?

Jon-Michial Carter
Written by Jon-Michial Carter

Medicare's Annual Wellness Visits (AWVs) play a pivotal role in proactive care management, but patients often don’t understand what these visits entail and, equally importantly, what they don’t cover. 

Patients and providers alike must recognize that AWVs primarily focus on preventive services and wellness planning rather than serving as a platform for addressing acute medical concerns or providing diagnostic tests.

AWVs allow patients to engage in comprehensive discussions with their healthcare providers, review their individual risks and medical history, and develop a personalized prevention plan. Properly administered AWVs can improve patients' quality of life and clinical outcomes. 

Patients often confuse these annual check-ups with their yearly physical exams, yet the two appointments vary in their procedures and intended outcomes. 

In this article, we will explore what is not covered by Medicare's AWVs, the importance of comprehensive healthcare planning beyond routine wellness visits, and how to integrate AWVs into your practice’s workflow by implementing AWV software.

What is the purpose of a Medicare Annual Wellness Visit? 

Medicare’s Annual Wellness Visits (AWVs) are used to develop proactive and preventative wellness plans by observing a patient’s risk factors, family medical history, and current health status. AWVs can identify and eliminate gaps in care, potentially preventing disease, injury, and disability. They are also part of Medicare’s broader strategy to shift the healthcare landscape from traditional fee-for-service models to value-based care, emphasizing quality, efficacy, and respect for patient preferences.

The ultimate goal of AWVs is to actively engage patients in their healthcare and facilitate better clinical outcomes. This service provides a wellness roadmap that mitigates long-term risks of developing or worsening chronic illnesses. 

The purpose of an AWV is not to treat previously existing healthcare diagnoses, review medications, or discuss newly emergent patient concerns, although an AWV can be added to a visit focused on these other needs. But the main goal of AWVs is to provide an intentionally broad picture of a patient’s baseline health, which is then leveraged to plan proactive care and catch potentially serious health issues before they can develop into debilitating conditions. 

AWVs are fully covered by Medicare. Once a patient has been enrolled in Medicare Part B for over a year, they are eligible to receive an AWV once every twelve months. If they’ve been enrolled in Medicare for less than a year, they can receive a “Welcome to Medicare” visit instead. 

Learn more: The Ultimate Guide to Medicare Annual Wellness Visits

What is covered by a Medicare Annual Wellness Visit?

An AWV may include the following: 

  • The administration of a Health Risk Assessment (HRA)
  • Assessment of a patient’s familial medical history
  • Measurement of height, weight, and blood pressure
  • Evaluation of cognitive function
  • Risk factor identification 
  • Functional ability assessment
  • Behavioral health screenings
  • Advance Care Planning
  • The creation of a personalized care plan that aims to reduce risk factors, close gaps in care, and promote optimal quality of life for each patient

What is not covered by a Medicare Annual Wellness Visit? 

Medicare’s AWVs do not cover: 

  • Physical examinations
  • Vaccinations
  • Medication prescription or adjustment
  • Chronic illness treatment
  • Sick visits
  • Diagnosis of conditions 
  • Any type of bloodwork, lab tests or panels, or X-rays

AWVs are not meant to treat or discuss pre-existing conditions or diagnose new or developing conditions. Those services are provided by regular provider visits. An AWV has preventative, holistic goals, as outlined by Medicare and CMS (Centers for Medicare and Medicaid Services).

That said, an AWV can be combined with a regular visit to receive care for a chronic condition. But the care for the chronic condition will be billed separately, not counted as part of the AWV. 

Physical examinations

Annual physical examinations are routine medical visits familiar to most patients. These often consist of the collection of vital signs like temperature, heart rate, blood pressure, and BMI (Body Mass Index). Physical examinations may also include bloodwork, urinalysis, visual examinations for moles and lesions, vision acuity, and a general assessment of organ functionality. 

Physical exams help providers understand a patient’s current health conditions, whereas AWVs are designed to improve overall health by taking a broad, holistic view of a patient’s history and risk factors. 

For example, in an annual physical, a provider searches for warning signs of melanoma on an individual’s body. During an AWV, a provider would ask the patient questions to determine the potential risk for familial melanoma. Both are crucial to the patient’s current and lasting health prospects, but they differ in execution and are seen as distinct services by Medicare. 

Many patients conflate an AWV with their yearly physical. This misunderstanding is one of the most common points of confusion around the AWV service and often leads to patient frustration and dissatisfaction. Practices and providers alike must create clear, specific messaging that delineates the two appointments as distinct and separate services. 

While AWVs and annual physicals are complementary and both provide critical insight into a patient’s health, an AWV does not consist of the physical examination of a patient. If a healthcare provider does administer physical examinations during the AWV, those will need to be billed separately. 

Learn more: The difference between Annual Wellness Visits and Annual Physical Examinations

Bloodwork, X-rays, and lab tests

Bloodwork, X-rays, lab tests, and any other medical biometric data collection are explicitly not covered under Medicare’s Annual Wellness Visit. These ancillary procedures are often performed in conjunction with an annual physical or a sick visit. They help the healthcare provider assemble a robust picture of a patient’s physical health, identify the root cause of a patient’s health issues, and evaluate the success of current medications and treatments.   

None of these fall within Medicare’s stated vision for the AWV, and a patient will be charged for these services separately. However, in the course of an AWV, it is very likely a provider may identify missing screenings or panels in a patient’s medical history. They may subsequently perform these procedures themselves or refer the patient to a specialist. Since these procedures fall beyond the scope of the AWV, the provider should warn the patient that they may be responsible for copays and deductibles.  

For example, suppose a patient reveals a history of diabetes in their family. In that case, a provider may wish to perform blood work like an A1C test to assure the patient is not prediabetic or otherwise at risk. However, that process will need to be billed separately from the AWV. The purpose of the AWV is to gather information about a patient’s health, identify relevant gaps in care, and chart a proactive, preventative care plan. An AWV is not meant to ascertain if the patient is diabetic at that moment–that’s a separate test. 

Treatments for chronic illness 

Medicare does not cover Annual Wellness Visits if they are used to discuss, plan, or alter treatment for pre-diagnosed chronic illnesses, including high cholesterol, high blood pressure, or arthritis. This includes lab work, medication prescriptions or adjustments, evaluation of treatment plans, or discussion of chronic illness management. These discussions will need to take place separately from the AWV. 

During an Annual Wellness Visit, healthcare providers will assess a patient’s medical history, chronic illness diagnoses, and prescribed medications to establish a comprehensive understanding of the patient’s health. 

However, AWVs are not designed to address illnesses previously diagnosed by healthcare providers. Patients should already be engaged in treatment plans for these conditions and in regular communication with providers, specialists, and care managers about their progress and concerns. Preventative care programs like Chronic Care Management can help with this. An AWV, on the other hand, is more holistic. 

The AWV aims to create proactive care plans, and if the appointment becomes dominated by discussing previously diagnosed illnesses, there is little time to look forward and meaningfully plan for the future. Therefore, if chronic illness treatment is discussed during an AWV, the patient will be charged a copay and/or deductible for the separate service.

Treatments for new illnesses and sick visits

Annual Wellness Visits should not be used to diagnose new conditions, prescribe new medications, or treat any sort of infection, injury, or discomfort. If a patient is experiencing pain or distressing symptoms, they should schedule a dedicated sick visit with their provider. In a sick visit, a physician can take the time to evaluate and treat these concerns properly. Some providers may choose to include an AWV before or after a sick-care visit, but they are separate services. 

Wellness visits are holistic by design. Time spent discussing a specific injury or illness detracts from the long-term wellness planning the AWV intends to facilitate. While the illnesses and injuries a patient experiences will factor into their future health and wellness goals, the actual treatment of these conditions is a separate service. 

Learn more: The Ultimate Medicare Annual Wellness Visit Checklist for Providers 

Why are these services not covered by an Annual Wellness Visit?

Medicare Annual Wellness Visits focus intentionally on preventative care and creating a roadmap for optimal long-term patient health. Focusing on pre-existing chronic conditions, injuries, or physical examinations and concerns could potentially hinder a provider’s ability to devote the necessary attention to holistic, futuristic wellness planning. Therefore, Medicare clearly distinguishes between AWVs and other routine appointments, offering narrow coverage to encourage patients and providers to take advantage of the often-underutilized AWV service. 

Should your practice offer out-of-coverage services during an Annual Wellness Visit?

Ultimately, whether non-covered services are offered during a scheduled AWV is up to the individual discretion of a practice. Providers can offer services that fall outside the scope of an AWV during the appointment, though these will need to be billed separately and result in payment by the patient. Therefore, it is crucial to master clear and effective messaging to patients around expectations and coverage before the appointment. 

Some patients prefer to combine their AWV with topics not covered under their insurance plan rather than schedule a separate appointment. Other patients may prefer to strictly stick with the stated purview of the AWV and avoid extraneous or unexpected charges.  

Encourage patients to contact their insurance providers with any further questions about what is covered and what their coinsurance or copayments will be. This eliminates confusion and frustration, improves communication between providers and patients, and facilitates higher patient satisfaction. 

If your practice uses AWV software, like ChartSpan’s proprietary RapidAWV™, combining wellness visits with sick visits, medication refills, or other standard appointments may be easier. With RapidAWV™, patients can complete the preliminary Health Risk Assessments (HRAs) on an iPad, desktop, or mobile device from the comfort of the waiting room. This creates a frictionless integration of the AWV into both the practice workflow and the patient’s appointment. However, your office should communicate clearly with the patient beforehand about the limitations of coverage to establish proper expectations. 

How to correctly bill Annual Wellness Visits

AWVs can be performed by a variety of healthcare professionals. Specialists like neurologists and cardiologists, primary care physicians, nurse practitioners, physician assistants, and dieticians are just some of the healthcare workers who can perform AWVs and subsequently bill these appointments to Medicare. 

However, Medicare patients are only eligible to be reimbursed for one AWV per twelve-month calendar year. If your patient’s cardiologist billed CMS for an AWV last month, your claim will be denied if you try to submit a reimbursement for the same service. Therefore, real-time eligibility checks within the HIPAA Eligibility Transaction System (HETS) database are crucial to the success of your AWV enterprises. AWV software, like RapidAWV™, offers up-to-date identification of eligible patients. This technology ensures your practice does not face coverage denials and any resulting complications. 

It is also essential that your practice employ the correct AWV CPT codes when billing CMS for these services. CPT codes differ based on distinct phases within the AWV program. Ensuring your team understands the distinctions between each code will help streamline billing processes and safeguard your practice against reimbursement rejections. 

Seamlessly implement AWVs with ChartSpan’s industry-leading RapidAWV™ software

The challenge with AWVs: AWVs remain an underused resource within the healthcare space despite studies demonstrating that they are correlated with reduced hospitalizations and readmissions, lower healthcare costs, and increased usage of preventative services. Over 80% of eligible Medicare recipients do not take advantage of these annual wellness planning sessions. 

Furthermore, practices create an additional source of recurring revenue when they integrate AWVs into their clinical workflow. The administration of AWVs can net practices between $118-174 in reimbursements per visit*. When paired with other preventative services, like obesity or smoking cessation consultations, these reimbursements can be even higher. 

Integrating a new service into your practice’s workflow can be cumbersome and time-consuming, especially one as misunderstood as Medicare’s AWV program. If patients do not understand the purpose or scope of AWVs, they are unlikely to take advantage of them. This can be all the more frustrating for your practice if you devote significant internal resources to creating an AWV program that patients find too complicated or confusing to use. 

*Results may vary by provider. 

ChartSpan’s solution: Streamline your practice’s administration of AWVs through ChartSpan’s RapidAWV™ software. The customizable HRAs generate preventative care plans personalized to every patient’s needs, risks, and lifestyle factors. Our software then presents you with 5 to 10-year care plans to share with patients. 

Our RapidAWV™ software is compatible with various devices, including desktops, tablets, and mobile phones. The Health Risk Assessments are designed to be senior-friendly and easy to complete. Whether the patient is there exclusively to receive an AWV or is pairing it with another appointment, these HRAs expedite the process without sacrificing the integrity or quality of the care provided to the patient.

With real-time eligibility checks against CMS’s HETS database, RapidAWV™ ensures reimbursement for every AWV administered by your practice, eliminating redundancies for your patients, simplifying your practice workflow, and preserving the added revenue stream. Our trained team of clinical professionals will assist you and your staff throughout the integration, ensuring that your team is confident with the new processes.  

Speak with an expert to learn more about how ChartSpan can help your practice improve clinical outcomes and capture additional revenue through the frictionless implementation of our industry-leading AWV software. 

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