With Medicare, you should understand the difference between a Routine Physical Exam versus a Wellness Visit, or it could cost you!
Federal law prohibits the Original Medicare health care program from paying for annual physical exams, and patients who receive them may be responsible for the entire cost amount out of pocket.
However beneficiaries are not responsible for paying anything for just an “Annual Wellness Visit,” which Medicare covers in full as a preventive service.
The Annual Wellness Visit generally does not include a full physical exam, except to check routine measurements such as height, weight and blood pressure.
A Routine Physical Exam typically involves an exam by a doctor along with bloodwork or other tests without relationship to treatment diagnosis for a specific illness, symptom, complaint, or injury.
If an Annual Wellness Visit goes beyond the bounds of the specific covered preventive services into diagnosis or treatment, whether at the urging of the doctor or the patient, Medicare beneficiaries will typically owe a copay or other charges.
The difference between a Wellness Visit and an Annual Exam is not as major an issue for "Medicare Advantage" members, as most plans offer both a $0 copay or a low dollar copay depending on the specific Medicare Advantage plan.
Also keep in mind, some preventive activities such as a preventive screening colonoscopy can turn into an outpatient surgical procedure, when it is considered to be diagnostic. In that case, a copay or coinsurance will generally apply, and it will no longer be considered just be a $0 copay preventive screening.
Medicare Coverage of Physical Exams - Know the Differences!
- Annual Wellness Visit (AWV) Visit to develop or update a personalized prevention plan, and perform a health risk assessment. Covered once every 12 months. Patient doesn’t pay anything (if provider accepts assignment).
- Initial Preventive Physical Examination (IPPE) Review of medical and social health history, and preventive services education. Covered only once, within 12 months of Part B enrollment. Patient doesn’t pay anything (if provider accepts assignment).
- Routine Physical Examination - Exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury. Not covered by Medicare; prohibited by statute. Patient pays 100% out-of-pocket.
For more detailed information in a .PDF file, click on this web link below:
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For a related blog post I wrote a while back, click on the web link below:
Does Original Medicare Cover Annual Physicals?
Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf
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