We have had several questions regarding what is included in your annual gyn exam. While we have you review and sign our annual exam billing policy at your appointment, we thought it was best we post it online as well. We want to make sure you are aware of important information regarding billing associated with this visit. Our office understands that the federal regulations related to billing and coding rules can be confusing and hope this helps to clarify what your insurance will or will not pay for and allows you to make the best choice for your health.
We strive to offer you thorough comprehensive care and while we are happy to address additional problems during your visit (to the extent that is possible within the scheduled appointment time), please be aware that this additional counseling may fall outside what your insurance company considers part of the annual GYN wellness exam and, therefore, may incur additional costs to you. If you do NOT wish to address anything outside what your insurance includes as part of your annual wellness exam, please let your provider know during your appointment. We will be happy to schedule you a separate office visit to address these issues or concerns on a different day.
From an insurance standpoint, your Annual Wellness Exam INCLUDES:
Review of your history and physical exam (including a breast exam and pelvic exam).
Pap smear, if needed (beginning at age 21).
Routine counseling on medical conditions and risk factors such as STD/STI prevention (STD/STI screening isn’t automatic but can be requested if at risk.), diet and exercise, smoking cessation, self-breast exams, birth control, menopausal symptoms, and hormone replacement therapy.
Routine health maintenance, which includes discussion and management of any existing conditions currently under control (not new).
From an insurance standpoint, your Annual Wellness Exam DOES NOT INCLUDE:
Procedures (biopsies, IUD insertion, ultrasounds, vaccine administration, etc.).
Discussion, counseling, or management of any new (acute) or chronic conditions. If a separate problem is identified during your annual wellness exam visit, we are required to submit separate claims based on
what is documented in the medical record of the service provided. This means two services may be billed–
the annual wellness exam and a problem-focused office visit, examples of which include but are not
limited to: vaginitis, urinary symptoms, decreased libido, abnormal bleeding.
Extensive counseling. If significant time is spent on counseling during your annual wellness exam visit, we are required to submit a claim based on this additional time. This means two services may be billed – the annual wellness exam and a consult visit, examples of which include but are not limited to: preconception counseling, hereditary cancer counseling, and extensive counseling for birth control, menopausal symptoms, and hormone replacement therapy.
Ancillary services (ex: lab, ultrasound, etc.) ordered to diagnose a condition based on acute (new) symptoms or to monitor a known chronic condition.
More lab info – if a lab is done for a specific diagnosis rather than screening, it will most likely not be covered under your Wellness/Preventive coverage benefits. For example, if you think you have a yeast infection and we test for this during your annual, you may owe part of or the entirety of the allowed amount. This does not mean the services were denied by your insurance company. Rather, the cost for the covered services was applied to your deductible or co-insurance according to your benefits and resulting in an out-of-pocket cost to you.
For compliance purposes, we bill without regard to patients’ individual insurance coverage and in accordance with nationally recognized standards. Unless an error has been made, we are not able to alter charges or diagnoses in order for rendered services to be covered or paid by a patient’s insurance plan as doing so would be considered fraudulent billing.
We hope that this explanation will help to clarify your care and our responsibility.
Yours in Health,
Dr. Nicole E. Williams, MD, FACOG, FACS