The Annual Wellness Visit


In the next few years, I would love to see the patients and providers stop saying that patients are coming in for their annual physical health exam.  You see, this is usually interpreted by each party as meaning something different.

For the patient, an annual physical health exam is usually interpreted as coming in for their once a year appointment where we are going to address their ‘laundry list’ of complaints and also get a physical done.  For women, this may mean a pap smear with breast exam as well. For men, this may mean a testicular exam and prostate check too.  The problem is, that it is not meant in the medical world to be an all-encompassing exam AND a let’s review your laundry list appointment too.

For the medical provider, an appointment for the annual physical health exam is just that.  An appointment for a head to toe physical exam with a review of the preventative medicine screenings for that patient.  The degree of detail that each provider goes into may be different.  As they don’t include this as a let’s check off the ‘laundry list’ of complaints visit, many clinics will bill you as a physical health exam and also as a focused problem exam at the same visit.

I have had patients come into my office very upset and leaving another clinic because this has happened.  In the patient’s eyes, it is one visit and should be billed under one code only, the preventative health exam code.  For them financially they were expecting it to be 100% covered or ‘free’ by their insurance.  All insurances with the PPACA or “Obamacare” are required to pay for one annual physical health exam per year without the patient paying a copay or towards their deductible so on the patient side there should be no bill or charge.  Instead, it was billed out as the preventative health exam code PLUS a regular office visit charge attached to it (that the patient was then responsible for and if they hadn’t met their deductible yet, at 100% out of pocket).  If you are Medicare, they don’t routinely pay for an annual physical health exam and so you will get charged and evaluation and management code for this visit anyway.

Why would the provider bill the services this way?  Well, because technically, that is the CORRECT way to bill that visit.  So, to prevent a large misunderstanding between patients and providers, we really need to BOTH understand what ‘is the objective’ of each party at their annual visit.  If you call to schedule an annual physical health exam, that is what the receptionist will schedule for you.  That may or may not, depending on the clinic, be viewed as ‘this is the time for their wellness visit’.  If not, the provider is really expecting you just to come get a head to toe physical exam.  That is all the time they have you blocked out for and if you are expecting different, you are now slowing down the schedule, the flow of the clinic and taking more than your allotted time.  The provider and clinic staff will most likely be frustrated and annoyed and you can most likely bet you are going to get charged for the two visits in one (if you are not on Medicare, it will be billed differently).

However, if you call and ask to be scheduled for an annual wellness visit with a physical health exam, the clinic, you and the provider should all be on the same page.  Each clinic should have a clear understanding of what this means.  Ideally, the front office staff or receptionist should have a clear understanding that you are wanting to review your preventative health issues, have coordination of care and review of your chronic health issues and a physical health exam in one visit.  Notice, I did not say time to review your ‘laundry list’ of complaints.  If the ‘laundry list’ of complaints does not match up with what should be covered in this visit, please be realistic and realize, these are problem complaints and really should be dealt with at another visit where the time and attention should be dedicated to hearing and addressing these complaints!

So what does this annual wellness visit really mean?  It means that once a year, your primary care provider (internal medicine physician, family physician, pediatrician or in some cases your OB/gynecologist (or any midlevel provider in these areas) should look at you as ‘the total patient’ and review your preventative issues AND coordination of chronic health issues.  Your primary care provider should be your home base and should be coordinating medications and treatment plans to look out for your best interest.

As to the medication list: are you on duplicated medications or medications meant to treat the same thing? Are you on high-risk medications that might potentially put you at harm?  Are you a combination of medications that may have a drug-drug interaction?  Are you on the appropriate medications to treat your specific health issues?  There are very strong evidence-based guidelines for medication treatment management of conditions such as diabetes, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, and chronic kidney failure that should be addressed.  If you are NOT on the appropriate medications for these conditions, why not?  This should be addressed.

There are also very strong evidence-based guidelines on the monitoring and regular management of these conditions.  Have you had the monitoring done recently that should be done such as follow-up stress tests, echocardiograms, and specific lab tests?  Then it is time to coordinate and get this done!

You see, as your primary care provider, it is my job to help you reduce your risk and ideally live the healthiest and longest life possible.  Yes, you may go see other specialists where they will focus on these issues each individually, but often times, things get missed or duplicated between seeing multiple providers.  It is the primary care providers job to coordinate all of this.  This also includes keeping you up to date on your preventative medicine screenings as well.

So, how will this visit usually be billed?  If you had a comprehensive head to toe exam done with this wellness time, it will include the physical health code with an attached annual wellness code.  This is different the attaching the evaluation and management code mentioned above.  If you are Medicare, it will be billed as an evaluation and management code with the annual wellness visit code attached.  Depending on the insurance, if they recognize and will cover the annual wellness visit code, it too should be paid for yearly at 100% with your physical, if not, the provider/clinic should write it off as part of their contractual agreement.  Medicare should be covering the billing of the annual wellness visit code yearly at 100% without charge to the patient.

The difference is, you are getting your money’s worth for the annual wellness visit with a physical health exam.  Really, isn’t that the kind of services you are really looking for in that visit?  I always recommend you check with your own insurance plan prior to obtaining services to guarantee coverage of services for that visit.  It is good to understand the specific language to use when you make this call to them to make sure you are on the same page (so many times people come in saying that they ‘approved it with their insurance’ when what they were wanting and what the insurance company was saying they would cover are two different things).   

Until next time, Pura Vida

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