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Writer's pictureJessica Zeff

Physician Billing for Wellness Visits vs. Physical Exams Under Medicare

Updated: Apr 11


Understanding Medicare's Billing Requirements


Medicare's billing regulations differentiate significantly between Annual Wellness Visits (AWVs) and routine physical exams, causing widespread confusion among healthcare providers and patients alike. Medicare covers AWVs but not routine physical exams. This distinction is crucial for compliance and patient billing.


Annual Wellness Visits (AWVs): A Closer Look


AWVs focus on preventive care, assessing health risks, and updating personalized prevention plans. They are covered annually after a beneficiary's first year on Medicare. Unlike routine physicals, AWVs do not require physical examinations but include activities like establishing medical and family history, assessing for potential depression, and reviewing functional ability.


The Billing Confusion


The confusion often arises when patients expecting a covered AWV receive a physical exam, leading to unexpected charges. Medicare mandates the use of specific HCPCS codes for billing AWVs, prohibiting the use of CPT codes 99381-99397, which are for comprehensive preventive medicine services which Medicare doesn’t cover because they’re considered routine. Providers are encouraged to obtain an Advance Beneficiary Notice (ABN), making patients aware of potential charges for services not covered by Medicare (Pub. 100-04, Chapter 50, section 50.2.1)​​.


Compliance Challenges and Recommendations

Healthcare providers face compliance risks when navigating the intricacies of Medicare billing for wellness visits. It's essential to adhere to Medicare’s guidelines, ensuring that all components of the AWV are documented and billed correctly. Utilizing a single template for all wellness-related visits can help avoid missing required components and improve compliance​​.


Implications for Practice


To mitigate billing and compliance risks, healthcare providers should:

  • Clearly distinguish between AWVs and physical exams in both scheduling and service delivery.

  • Use the correct codes for billing AWVs to avoid claims denials and ensure compliance.

  • Inform patients about the coverage differences between AWVs and physical exams to avoid unexpected billing issues.


Conclusion

Navigating the billing complexities of Medicare's AWVs and physical exams requires a clear understanding of the guidelines and proactive patient communication. By adhering to Medicare’s billing requirements and educating patients, healthcare providers can avoid compliance pitfalls and ensure a transparent billing process.


Do you have questions about this blog? Please contact jessicazeff@simplycomplianceconsulting.com.




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