Medicare Annual Wellness Visit

[Bram]

I’ve read at the links provided above. Very informative, particularly the “capture billing . com”, where Manny answers some Qs at the bottom of the page. He says there is lots of confusion about this.

I had no idea that Medicare doesn’t cover a routine annual physical exam! The language Medicare uses contributes mightily to confusion for patients, physicians, coders, & billers. Medicare markets the 100% covered Annual Wellness Visit, which most literate humans would interpret as an “annual physical”. But NO, there is a nuanced difference!

My dr codes what I thought was my annual exam as “99214 - Established Patient Office Or Other Outpatient, Visit Typically 25 Minutes”. Medicare has paid 80% & my secondary has picked up the rest. This has been the case for the last 3 yrs. I looked up DH’s Medicare EOBs, ditto for him.

 

[MBSC]

There must be some differences in Medicare plans. Our BC Medicare Advantage covers annual wellness visit and in addition includes an annual physical exam. You may have to pay a copay if you also are treated for a new medical condition or monitored for an existing condition at the same time you are getting your physical.

Yes, Medicare Advantage plans cover more preventive services than traditional Medicare.

My dr codes what I thought was my annual exam as “99214 - Established Patient Office Or Other Outpatient, Visit Typically 25 Minutes”. Medicare has paid 80% & my secondary has picked up the rest. This has been the case for the last 3 yrs. I looked up DH’s Medicare EOBs, ditto for him.

The provider is billing a sick person/pre-existing condition office visit. Medicare covers these.

Most Medicare patients have chronic problems to discuss at their wellness visits. CMS allows physicians to report both the problem-oriented visit and the wellness visit on the same day, and the revenue implications of reporting both services are significant. Of course, the problem-oriented visit must be medically necessary, and both the wellness visit and the problem-oriented visit must be documented.

...Many physicians fail to bill for Medicare annual wellness visits even though code G0438 pays $64 more than code 99214.

Reference: https://www.aafp.org/fpm/2016/0500/p30.pdf

 

[H2ODude]

Sounds to me like Harlee needs a new Dr. Somehow for last two years on MC I've been going in and getting what I'd call a physical w blood work, all I think I need. If my doc answered in inquiry about allergy and used that as justification to ding me $400 I'd be gone.

It's interesting that DW just had her annual at her Gyn, approved for mammo and bone density as well as colonoscopy. Should be good to go, right? Nope. MC won't allow the Gyn to take bloodwork so he sends her to her rarely seen GP for that. Nuts I tell ya.

 

[HadEnuff]

Sounds to me like Harlee needs a new Dr. Somehow for last two years on MC I've been going in and getting what I'd call a physical w blood work, all I think I need. If my doc answered in inquiry about allergy and used that as justification to ding me $400 I'd be gone.

It's interesting that DW just had her annual at her Gyn, approved for mammo and bone density as well as colonoscopy. Should be good to go, right? Nope. MC won't allow the Gyn to take bloodwork so he sends her to her rarely seen GP for that. Nuts I tell ya.

Would one typically wait for some sort of authorization from MC before having the bloodwork done? How did you find out that MC wouldn't allow the GYN to take the bloodwork?

 

[Gotadimple]

Would one typically wait for some sort of authorization from MC before having the bloodwork done? How did you find out that MC wouldn't allow the GYN to take the bloodwork?

No authorization would ever be given in this situation: the GYN specialty has no need to review bloodwork. This may not be Medicare - but the state laws that govern medical professionals.

 

[harllee]

No authorization would ever be given in this situation: the GYN specialty has no need to review bloodwork. This may not be Medicare - but the state laws that govern medical professionals.

I do have some blood work done at my GYN--to check for hormone levels, etc.

 

[Katsmeow]

Several things:

1. It is astonishing to me that some people seem to be looking for a way to criticize the OP for what is clearly the fault of either the physician or the billing department. She was clear that she wanted an annual wellness visit. She knew what it was and didn't ask for anything else. Even if the physician did ask about her allergies (which is not clear), at most the physician seemingly would have been able to bill for that problem -- it wouldn't have converted the visit to a physical. If the billing office won't correct it, if I was her I would consult with the physician to try to get it cleared up. If that didn't work I would send a strong letter and would switch physicians.

2. I don't think the annual wellness visit is all that valuable. Note that some practices require patients to have one. DH is on Medicare (I'm not yet) and our doctor has a written statement on their website that patients must do the annual wellness visit to stay part of the practice. This is because Medicare is wanting physicians to do them in order to get full reimbursement for Medicare services. The statement is clear that the wellness visit is not a physical and is clear about what is and is not included. FWIW, DH went in and did the visit with the nurse practitioner and it was properly billed as such.

3. About the lab tests run and that were covered. First, Medicare does cover some preventative services. They just don't cover a generic physical. So, a mammogram would be covered annually for example. There are lists of the preventative services covered and how often.

Routine blood work isn't covered if it is just for preventative purposes. I did a physical a few months ago and routine blood work was done. All of this was covered as I am not on Medicare. But, routine blood work wouldn't be covered on traditional Medicare if it was just done routinely as a preventative service. That said - it is covered if it is to diagnose or monitor something. So, for example, I have low Vitamin D. So if I was on Medicare I am sure my Vitamin D testing would be covered since I have that history. I would guess cholesterol testing would be covered for most people on Medicare because many would either have high cholesterol already or due to age would be at risk. The point being that blood work doesn't have a particularly high bar it is has to meet to be considered to be to diagnose or monitor something.

 

[harllee]

OP here, I am starting to look around for another doctor in my town to move to. So far I have been unable to find any doctors in other practices in my town that accept Medicare and are taking new patients. The practice I am with seems to have most the doctors in town that take Medicare. I am surprised at how many doctors do not take Medicare at all.

Any suggestions how to find a doctor that takes Medicare and is accepting new patients?

 

[braumeister]

It's not easy.
I asked the same question recently here.
http://www.early-retirement.org/forums/f38/finding-a-new-doctor-90477.html

 

[REWahoo]

Any suggestions how to find a doctor that takes Medicare and is accepting new patients?

My Medigap provider (Blue Cross/Blue Shield) has a website that assists their insured in finding a doc in their area. You might check to see if your Medigap provider does the same.

 

[H2ODude]

Would one typically wait for some sort of authorization from MC before having the bloodwork done? How did you find out that MC wouldn't allow the GYN to take the bloodwork?

The GYN told her that MC would not allow the GYN to do blood work, off to the GP for that. DW intends to go to GP and specify she wants the bloodwork that would be covered by MC. She has no real problems other than osteop. My blood work has been covered but only thing is I have some elevated LDL that I've been bringing down w diet and exercise.

 

[athena53]

I've been watching this thread with interest since I had my first wellness visit after enrolling in Medicare. I've been going to my gyno for annual checkups- no major health issues so I mostly want to monitor blood work.

So- I checked with the Medicare site. Her fee was covered, no problem. The bloodwork is a different story. Five tests of various components (lipids, Vitamin D-3, HbA1c, Thyroid-Stimulating Hormone and the count of red cells, white cells, etc.- were denied- total cost $814! I called Medicare and they said the doc did not submit reasons that the tests were medically necessary. So, gotta call the doc's office. I have borderline high cholesterol and fasting glucose so should at least be able to get the A1c and lipids approved.

Sigh. And I was SO happy to be out of the high-deductible Omabacare plan and enrolled in Medicare.

 

[H2ODude]

I've been watching this thread with interest since I had my first wellness visit after enrolling in Medicare. I've been going to my gyno for annual checkups- no major health issues so I mostly want to monitor blood work.

So- I checked with the Medicare site. Her fee was covered, no problem. The bloodwork is a different story. Five tests of various components (lipids, Vitamin D-3, HbA1c, Thyroid-Stimulating Hormone and the count of red cells, white cells, etc.- were denied- total cost $814! I called Medicare and they said the doc did not submit reasons that the tests were medically necessary. So, gotta call the doc's office. I have borderline high cholesterol and fasting glucose so should at least be able to get the A1c and lipids approved.

Sigh. And I was SO happy to be out of the high-deductible Omabacare plan and enrolled in Medicare.

In DW's case, her Gyn would not do those tests because MC would not allow. He referred her to primary care to get them. We're assuming such routine annual bloodwork would be covered at PC; DW intends to go in and ask for whatever MC allows for such bloodwork. NO IDEA why the Gyn could not have drawn the blood, but it was his assessment that it wouldn't pass MC test.

 

[harllee]

OP here. Today I checked my online account with my physician and saw that they had changed the coding for my appointment to annual wellness visit and resubmitted it to Medicare. Instead of a $400 bill the amount for a full physical (which I did not get) the amount submitted to Medicare for an Annual Wellness Visit was $160. The price difference must be the reason it has been so hard for me to get the coding changed, even though I had clearly asked for an annual wellness visit. I think the only reason it got changed was that I got my doctor involved.

Coincidently, I just received a letter from my doctor that said he is retiring. I am sorry that he is retiring--other than this billing problem and one time he was reluctant to give me antibiotics for a sinus infection I liked my doctor. But I am glad that he is able to retire (I think he is around age 60).

Anyway, he has recommended I go with a another doctor in his large practice--there are over 50 doctors in this practice at one location and many other doctors at other locations. Because of this billing issue I would like to go to another practice but so far I have not found one in my town that accepts Medicare and is also is taking new patients. It seems like a lot of doctors in my area do not accept Medicare. So I may be stuck with the same practice. For sure I am going to be careful about going in for a wellness visit in the future. Maybe I will just go in when I don't feel well so it will be covered by Medicare as a sickness visit.

 

[Dtail]

I've been watching this thread with interest since I had my first wellness visit after enrolling in Medicare. I've been going to my gyno for annual checkups- no major health issues so I mostly want to monitor blood work.

So- I checked with the Medicare site. Her fee was covered, no problem. The bloodwork is a different story. Five tests of various components (lipids, Vitamin D-3, HbA1c, Thyroid-Stimulating Hormone and the count of red cells, white cells, etc.- were denied- total cost $814! I called Medicare and they said the doc did not submit reasons that the tests were medically necessary. So, gotta call the doc's office. I have borderline high cholesterol and fasting glucose so should at least be able to get the A1c and lipids approved.

Sigh. And I was SO happy to be out of the high-deductible Omabacare plan and enrolled in Medicare.

That is interesting.
My brother is covered by ACA. He just had a yearly physical, blood work and a chest x ray for a grand total of $1.
I was eventually looking forward to not having to manage income for ACA purposes and worry when it could be overturned and now we have your Medicare story.

 

[athena53]

That is interesting.
My brother is covered by ACA. He just had a yearly physical, blood work and a chest x ray for a grand total of $1.
I was eventually looking forward to not having to manage income for ACA purposes and worry when it could be overturned and now we have your Medicare story.

Well, mine turned out OK- sort of. I never qualified for ACA subsidies and was also looking forward to being "home free" with Medicare since it had worked quite well for my late husband. I'm off the hook for the bloodwork- apparently since I didn't sign any consent form acknowledging that Medicare wouldn't pay for it the lab got stuck with the bill. I don't like that solution even though it means I don't owe anything; the lab didn't get paid and I don't know what it means for future checkups. I may just go with home cholesterol and HbA1c tests, which you can apparently buy at major drug chains. This are the only numbers I really see a need to monitor; once I get back to the blood bank (deferred after a trip to India) I'll get regular hemoglobin and platelet counts.

 

[Dtail]

Well, mine turned out OK- sort of. I never qualified for ACA subsidies and was also looking forward to being "home free" with Medicare since it had worked quite well for my late husband. I'm off the hook for the bloodwork- apparently since I didn't sign any consent form acknowledging that Medicare wouldn't pay for it the lab got stuck with the bill. I don't like that solution even though it means I don't owe anything; the lab didn't get paid and I don't know what it means for future checkups. I may just go with home cholesterol and HbA1c tests, which you can apparently buy at major drug chains. This are the only numbers I really see a need to monitor; once I get back to the blood bank (deferred after a trip to India) I'll get regular hemoglobin and platelet counts.

Yes, that could be a way around it.
For many folks, your sugar levels, cholesterol and blood pressure can all be measured at home and perhaps save other tests for Medicare.
However, I will continue to not take any home version of a colonoscopy.

 

[Moemg]

I went for a medicare Wellness yesterday only because my physician's office would not stop hounding me about it . What a total waste of time .If they cut Medicare I hope this is the first thing to go .Questions such as are you sexually active and Is it with Men is a joke . I felt like answering sheep but they are hard to come by .She kept on asking for my pain level which is a zero so she asked me again and again .It was still zero .No examination just endless questions . I am not going next year no matter how much they bug me . I see a Physician several times a year this is unnecessary .

 

[Gotadimple]

I went for a medicare Wellness yesterday only because my physician's office would not stop hounding me about it . What a total waste of time .If they cut Medicare I hope this is the first thing to go .Questions such as are you sexually active and Is it with Men is a joke . I felt like answering sheep but they are hard to come by .She kept on asking for my pain level which is a zero so she asked me again and again .It was still zero .No examination just endless questions . I am not going next year no matter how much they bug me . I see a Physician several times a year this is unnecessary .

They don't get paid if you don't go. All the questions are probably dictated by Medicare - they don't see the answers but do require the Dr. to ask the questions.

 

[aja8888]

I went for a medicare Wellness yesterday only because my physician's office would not stop hounding me about it . What a total waste of time .If they cut Medicare I hope this is the first thing to go .Questions such as are you sexually active and Is it with Men is a joke . I felt like answering sheep but they are hard to come by .She kept on asking for my pain level which is a zero so she asked me again and again .It was still zero .No examination just endless questions . I am not going next year no matter how much they bug me . I see a Physician several times a year this is unnecessary .

In comparison, I had mine two months ago and had an EKG, look over by the doc, a review of my meds, blood work including PSA and test for testosterone, that stupid questionnaire (joke, but I gave all positive answers (LOL)). I also got my new pneumonia shot. I was there for an hour, at least.

Then doc went over the results of the blood work with me once the lab data was back.

Maybe you should look into a different doc for the annual wellness exam?

 

[travelover]

In comparison, I had mine two months ago and had an EKG, look over by the doc, a review of my meds, blood work including PSA and test for testosterone, that stupid questionnaire (joke, but I gave all positive answers (LOL)). I also got my new pneumonia shot. I was there for an hour, at least.

Then doc went over the results of the blood work with me once the lab data was back.

Maybe you should look into a different doc for the annual wellness exam?

My experience was similar. I expected just a clip board exam with questions, but the doc did a pretty standard exam, including blood work and an EKG though no PSA test and a mental simple acuity test. As far as I can tell, Medicare paid for it all.

 

[Moemg]

Mine was done by the Physician's Assistant and no blood work or any exam just questions . She did order an EKG to be done in the future . Maybe I need to change Physician's ?

 

[aja8888]

Mine was done by the Physician's Assistant and no blood work or any exam just questions . She did order an EKG to be done in the future . Maybe I need to change Physician's ?

This was my 9th year of Medicare wellness exams and every year blood work was done. Something is not right with your physician? Maybe she doesn't understand what is available under the wellness exam?

The Medicare website will probably outline what you can have done each year during the wellness exam.

 

[MBSC]

This was my 9th year of Medicare wellness exams and every year blood work was done. Something is not right with your physician? Maybe she doesn't understand what is available under the wellness exam?

Only the services listed below are part of the wellness visit.

Either the provider is billing under one of the other preventive screenings listed in this link or, since you mentioned medications in one post, is billing the blood work on a separate claim line under a diagnostic ICD-10 code.

Covered diagnostic lab services are paid at 100% by Medicare, not the usual 80/20 split. I have known some to confuse the 100% lab payment for 100% preventive payment.

• A "Welcome to Medicare" preventive visit: You can get this visit only within the first 12 months you have Part B. This visit includes a review of your medical and social history related to your health and education and counseling about preventive services, including these:
  • Certain screenings, shots, and referrals for other care, if needed
  • Height, weight, and blood pressure measurements
  • A calculation of your body mass index
  • A simple vision test
  • A review of your potential risk for depression and your level of safety
  • An offer to talk with you about creating advance directives.
  • A written plan letting you know which screenings, shots, and other preventive services you need. Get details about coverage for screenings, shots, and other preventive services.

This visit is covered one time. You don’t need to have this visit to be covered for yearly "Wellness" visits.

• Yearly "Wellness" visits: If you've had Part B for longer than 12 months, you can get this visit to develop or update a personalized prevention help plan. This plan is designed to help prevent disease and disability based on your current health and risk factors. Your provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your provider develop a personalized prevention plan to help you stay healthy and get the most out of your visit. It can also include:
  • A review of your medical and family history
  • Developing or updating a list of current providers and prescriptions
  • Height, weight, blood pressure, and other routine measurements
  • Detection of any cognitive impairment
  • Personalized health advice
  • A list of risk factors and treatment options for you
  • A screening schedule (like a checklist) for appropriate preventive services. Get details about coverage for screenings, shots, and other preventive services.
  • Advance care planning

This visit is covered once every 12 months.

Source: https://www.medicare.gov/coverage/preventive-visit-and-yearly-wellness-exams.html

Your costs in Original Medicare:

You pay nothing for Medicare-approved covered clinical diagnostic laboratory services.

Reference: https://www.medicare.gov/coverage/clinical-lab-services.html

Unlike most other Medicare services, there is no beneficiary cost sharing for clinical lab services.

Reference: http://www.medpac.gov/docs/default-...ent_basics_16_clinical_lab_final.pdf?sfvrsn=0