Published monthly in The Marysville Advocate, "To Your Health" articles provide information about health and wellness topics. This month's article was written by Jill Bergmeier, Community Physicians Clinic Director.
MEDICARE WELLNESS EXAMS: Making sense of the 3 exam types & understanding your coverage
Medicare wellness exams: What are they? What do I as a patient ask for? Who is going to pay for this?
Unfortunately, there is a lot of confusion as to what is included in each exam, and how it is reimbursed by Medicare. Medicare does not make things easy! At CMH, we feel it is important for all Medicare recipients to understand their benefits fully. This understanding will help you receive optimal covered healthcare to promote wellness.
There are 3 exams that cause confusion. Let’s take a closer look at what each covers and how they’re billed.
Initial Preventative Physical Exam (IPPE): This exam is to be done within your first 12 months of receiving Medicare. If done within this time frame, this exam should be covered. The following are included:
• Review of patient’s medical and social history
• Review of patient’s risk factors for depression and other mood disorders
• A physical examination
• End of life planning
• Education, counselling and referral based on the previous four components, and for other preventative services
Annual Wellness Visits (AWV): This is not an annual routine preventative physical exam! Preventative routine physical exams are much more comprehensive than the AWV. The AWV is comprised of the following elements:
• Medical and family history
• List of current medical providers
• Height, weight, BMI, BP and other appropriate vital sign measurements
• Detection of cognitive impairment
• Review of risk factors
• Review of functional ability
• Establish a written screening schedule for next 5-10 years
• Establish a list of risk factors
• Provide advice and referrals to health education and preventative counseling services
It is very important to understand that if any problems are identified by your provider as they go through the above elements with you, they are not able to address a treatment plan for these at this visit. If problems are identified, you will need to schedule another appointment to address whatever those are. If the provider goes on to address the problems and create a treatment plan during the AWV, the visit will not be covered by Medicare. For example: if your blood pressure is found to be running high, and your pulse is a bit irregular, they will ask you to make another appointment to address this. By doing so, your AWV will be covered and your next appointment to address the problems will also be covered.
Comprehensive Preventative Medicine Exam: The purpose of this exam is to screen for disease, promote a healthy lifestyle, and assess an individual’s potential risk factors for future medical problems. Any clinical laboratory tests or other diagnostic services performed at the time of the wellness visit may be subject to a copayment, coinsurance or deductible, as applicable. This exam is comprised of the following elements:
• Vital signs
• General appearance
• Heart exam
• Lung exam
• Head and neck exam
• Abdominal exam
• Neurological exam
• Dermatological exam
• Extremities exam
• Male physical exam: testicular, hernia & prostate exams
• Female physical exam: breast & pelvic exams
• Counseling to include healthy behaviors and screening services
The comprehensive Preventative Medicine visit for either an established patient or a new patient is NEVER covered by Medicare. Sometimes, a secondary insurer will pay for these services, but it depends on your individual coverage and benefits.
Please note that Medicare rules are complex and change all the time. What is current information today may be incorrect tomorrow. Always check with your local Medicare carrier. For more detailed information, please visit www.medicare.gov.
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