Coding: Physical exam vs. annual wellness visit

© khemmanat - stock.adobe.com

Question: Can you tell me the difference between an annual physical and an Annual Wellness Visit (AWV)?

Answer: While both types of exams have prevention in mind, there are many differences between them.

An annual physical is a more extensive exam than a Medicare Annual Wellness Visit. A typical annual physical is a “hands-on” type of visit, including a physical exam and any blood work or lab tests that may be part of the exam or necessary for the patient’s chronic stable problems.

Alternatively, the AWV is a “hands-off” risk assessment.The purpose of the AWV is to identify gaps in care, improve the quality of care that a provider delivers, and help paint a picture of a patient’s current state of health to create a baseline for future care.

What’s Included in a Physical Exam?

An annual physical exam is an assessment of your body’s health. The primary purpose is to look for health problems.

During the exam, your doctor uses his or her senses – mainly sight, touch and hearing – to gauge how your body is performing. Based on what’s learned, your doctor may ask you to have tests to discover or rule out possible health problems.

The list below shows some of the things a physician may do during a physical exam.

Visually check the patient’s body overall for signs of existing health issues:

• Perform an exam of the patient’s eyes, ears, nose and throat for potential problems
• Listen to the patient’s heart and lungs to detect irregular sounds
• Test motor function and reflexes
• Perform pelvic and rectal exams
• Measure height, weight and blood pressure

Submit or order urine and blood samples for lab testing, for screening purposes and for ongoing chronic conditions

As a rule, Medicare does not cover an annual physical. The exam and any tests your doctor orders are separate services, and you may have costs related to each depending on your Medicare plan.

What’s Included in a Medicare Wellness Visit?

A Medicare AWV, also called a wellness exam, is an assessment of the patient’s overall health and well-being. The primary purpose is prevention – either to develop or update the patient’s personalized prevention plan. Medicare covers an AWV once every 12 months (11 full months must have passed since your last visit), and patients are eligible for this benefit after they have had Part B for at least 12 months.

During the exam, a physician or APP (usually a primary care provider) combines information from the visit with the patient’s medical record to gauge your risk for common preventable health problems such as heart disease, cancer and type 2 diabetes. Based on what’s learned, your doctor creates your personal prevention plan with a checklist of screenings you need to have.

The list below shows what should be performed during a wellness exam.

Review your health risk assessment (questions you answer about your health)

• Confirm patient’s medical and family history
• Record current medications (including prescriptions and over the counter medications) and providers
• Measure and document patient’s height, weight and blood pressure
• Look for signs of memory loss, dementia, frailty, depression, stress, pain and fatigue
• Review behavioral risks, including tobacco use, physical activity, nutrition, oral health, alcohol consumption, sexual health, motor vehicle (i.e., seat belt use), and home safety
• Assess activities of daily living (ADLs)
• Document patient’s health risk factors and treatment options, including referrals to education and counseling programs
• Provide personalized health advice
• Develop a screening schedule (like a checklist) for the preventive services recommended for you
• Review potential risk factors for Opioid Use Disorder (OUD)
• Screen for potential Substance Use Disorders (SUDs)
• Advance Care Planning (e.g., living will, health care power of attorney), if patient chooses to

Medicare Part B covers an Annual Wellness Visit and many preventive screenings with no copay or deductible. However, you may have to pay a share of the cost for certain recommended tests or services.

Renee Dowling is a compliance auditor for Sansum Clinic, LLC, in Santa Barbara, California.