Medicare Compliance & Reimbursement

Question: What’s the difference between an annual well visit and a well-woman visit? A new, female patient who’s a Medicare Part B beneficiary wants an annual well visit but wants the type “that she doesn’t have to pay for.” What’s the difference?

Texas Subscriber

Answer: Medicare offers coverage for certain preventive services, including well visits. Your question didn’t mention whether the patient is new just to your practice or new to Medicare Part B as well.

Here are the differences between routine exams, according to the Medicare Learning Network:

The initial preventive physical exam (IPPE) is covered only once, per lifetime, within 12 months of Part B enrollment. Medicare pays the cost of the exam if the “provider accepts assignment.” This exam is also called the “Welcome to Medicare” preventive visit.

An annual well visit is to develop or update a personalized prevention plan and perform a health risk assessment. Medicare covers this visit once every 12 months, if the patient hasn’t had an IPPE in the past 12 months (and hasn’t become a Part B beneficiary in the past 12 months). Again, the patient pays nothing if the provider accepts assignment.

Medicare allows routine physicals, which are exams performed “without relationship to treatment or diagnosis,” but they are not covered by Medicare, because such exams are prohibited by statute. The patient must pay 100 percent out of pocket. These rules also apply to well-woman exams.

So, with these definitions in mind, you should find out when the patient first became eligible for Part B benefits, and then, if she’s eligible for an annual wellness visit, clarify exactly what is involved.