“Wait, This Isn’t Free?” – What Actually Counts as a Wellness Visit
I was at my annual check-up recently when I overheard a frustrated couple at the front desk. One of them had just finished their appointment, only to be told a copay was due. Their reaction? “But this was a wellness visit. It’s supposed to be free!”
The front desk staff tried to explain, but neither side felt heard nor understood.
As someone who works in healthcare consulting, I’ve seen this scenario play out more times than I can count. And in that moment, it hit me: if the average patient is this confused, we need to do a better job explaining what a wellness visit is—and what it isn’t.
What Is a Wellness Visit, Anyway?
A wellness visit is essentially a preventative health check. Think of it like taking your car in for routine maintenance before there’s a problem, not after the check engine light is already on.
These visits are typically covered in full by most insurance plans, thanks in large part to the Affordable Care Act. That means no copay, no deductible, and no surprise bills as long as the visit remains preventive.
Wellness visits often include:
Reviewing your medical and family history
Taking routine measurements (blood pressure, weight, etc.)
Discussing health goals and risks
Ordering age-appropriate screenings or vaccinations
Counseling on topics like diet, exercise, or smoking cessation
Planning next steps for keeping you healthy
Types of Wellness Visits
Not all wellness visits are the same. Each is tailored to the patient’s age, insurance type, and clinical guidelines. Here’s a quick breakdown:
Pediatric Well-Child Visits
(Typically ages 0–17, covered under commercial plans and Medicaid)
Follows a schedule recommended by the American Academy of Pediatrics (e.g., 2 months, 6 months, 12 months, etc.)
Includes developmental screenings, immunizations, growth tracking, and anticipatory guidance
Covered annually, or more frequently in infancy and early childhood
CPT Codes:
99381–99385 (new patients)
99391–99395 (established patients)
Adult Annual Preventive Visits
(Usually ages 18–64, under commercial or marketplace plans)
Includes review of medical history, screenings (e.g., cholesterol, diabetes, cancer), and lifestyle counseling
Immunizations may be included or billed separately
Typically allowed once per calendar year
CPT Codes:
99385–99387 (new patients)
99395–99397 (established patients)
Medicare Annual Wellness Visits (AWVs)
(Ages 65+, covered by Original Medicare and some Medicare Advantage plans)
Important: This is not a physical exam. It’s a structured conversation and assessment focused on planning long-term preventive care.
Initial AWV (G0438): Available once, 12 months after Part B eligibility
Subsequent AWVs (G0439): Annually after the initial AWV
Includes cognitive screening, functional assessment, fall risk, and creation of a personalized prevention plan
Other related codes:
G0402 – Welcome to Medicare visit (within first 12 months of enrollment)
G0444 – Depression screening
G0442/G0443 – Alcohol misuse screening and counseling
Other Preventive Services Often Combined with Wellness Visits
These aren’t wellness visits by themselves, but are often bundled or scheduled alongside:
Pap smears and pelvic exams (Q0091 for Medicare)
Mammograms, colonoscopies, or lung cancer screenings (often ordered, not performed, during wellness visits)
Immunizations (flu, HPV, shingles, Tdap—may be billed separately depending on payer)
Pro Tip: Always Verify Coverage
Even if a visit is labeled “preventive,” services like labs, tests, or treatments added during the visit might be billed separately. Patients should check:
Whether their plan follows ACA preventive guidelines
If the provider is in-network
What’s included vs. what’s considered diagnostic
When a Wellness Visit Turns Into a Sick Visit
Here’s where the confusion begins.
Let’s say you're at your wellness visit and casually mention that your knee has been hurting for the past few weeks. Or maybe you ask for a refill of your blood pressure medication and mention your readings have been creeping up.
The moment your provider starts diagnosing, treating, or managing a specific problem, the visit is no longer strictly preventive. That part of the visit becomes diagnostic and may be billed separately from your wellness visit, sometimes triggering a copay or being applied to your deductible.
Here’s the key point: this doesn’t mean your doctor did anything wrong, or that you shouldn't speak up about your concerns. It just means the visit is now doing double duty, and the billing will reflect that.
How to Bill When a Wellness Visit Becomes a Sick Visit
When both preventive and diagnostic services are provided during the same appointment, here’s how to bill it correctly:
1. Bill for the Wellness Visit:
Use the appropriate preventive CPT code based on the patient’s age and insurance guidelines. For example:
99385–99387 for new patients
99395–99397 for established patients
Medicare patients may fall under:
G0438 (initial) or G0439 (subsequent) for Annual Wellness Visits
2. Bill for the Problem-Oriented Visit:
If the provider evaluates and treats an acute or chronic issue beyond the scope of the wellness exam, also bill an E/M code (99212–99215) based on complexity and time.
Modifier 25 is essential here.
Append Modifier -25 to the E/M code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day.
Example:
99396 – Preventive visit for a 45-year-old established patient
99213-25 – Problem-focused visit for new-onset knee pain
Be sure that both services are clearly documented. The wellness portion should cover standard preventive care, while the problem visit should show medical necessity and the work done.
Should You Reschedule Instead of Billing for Both?
In some cases, especially when patient expectations are sensitive or time is limited, rescheduling may be the better choice:
If the patient strongly believes the visit should be fully covered and is unaware of billing nuances
If the acute concern is complex and requires more time or testing than the wellness visit allows
If the provider feels documentation won’t support separate billing without risk of denial or audit
If clinic policy or provider preference is to keep wellness and problem-focused care separate
In these situations, providers can document the wellness components completed, explain to the patient how addressing the new concern would alter billing, and offer to reschedule a problem visit soon after.
Pro tip: A quick, empathetic script can go a long way:
“I’d love to help you with that concern, but it would change the visit type and possibly your coverage. Would you like to schedule a follow-up so we can give it the time it deserves and avoid unexpected billing?”
What You Can Do as a Patient
Understanding the rules can help you make informed decisions and avoid billing surprises:
Set expectations upfront: When checking in, let your provider know you're here for a wellness exam only.
Ask before you ask: If you bring up a new issue, ask whether it might shift the visit from preventive to diagnostic.
Plan ahead: If you have several concerns, consider booking a separate appointment to address them.
Review your insurance: Know what your plan covers so you’re not caught off guard.
What You Can Do as a Practice
For providers and clinic staff, this is where communication is everything:
Train front desk teams to explain the difference between preventive and diagnostic care using patient-friendly language.
Coach providers to clarify when a visit may include both services and what that means for billing.
Use signage or digital reminders to set expectations before patients walk into the room.
Make documentation consistent so coding and billing are accurate and defensible.
At Ignite Healthcare Solutions, we partner with organizations to reduce friction in these moments. We optimize front desk workflows, help staff communicate clearly and empathetically, and ensure billing practices reflect both compliance and compassion.
Why It Matters
That couple at the front desk wasn’t being difficult—they were just blindsided by a system that’s not always easy to navigate.
Healthcare billing shouldn’t feel like a trap. With the right systems and communication in place, wellness visits can be what they were always meant to be: a valuable, reassuring, and positive experience for patients—and a seamless process for providers.
Because wellness should feel like a benefit, not a bill.
