Documentation Requirements for Annual Wellness Visit

The Annual Wellness Visit (AWV) is a yearly appointment that provides the opportunity for healthcare providers to develop and update a personalized prevention plan for their patients. Medicare covers Annual Wellness Visit if the patients have had Medicare part B coverage for more than 12 months and have not received an initial preventive physical exam or AWV service within the last 12 months. Subsequent AWVs can be scheduled annually (11 full months after the month of the last AWV) as well. Physicians must document the components of AWV properly; this is important from the point of view of providing quality care and avoiding compliance problem that may lead to claim denial.

The documentation rules for AWVs are vastly different from that of a preventive physical exam. AWV requires a Health Risk Assessment that should be filled out by the patient and it will be reviewed by the physician along with the patient. Health Risk Assessment includes demographic data, self-assessment of health status, psychosocial and behavioral health risks and activities of patients in their daily life. The other documentation requirements are as follows.

Patient History

Document medical and surgical history including the illnesses, hospital stays, allergies, injuries and treatments. It is also required to document family history, current medications and supplements and current providers. The risk factors for depression and other mood disorders, the patient’s functional ability and other relevant details should be also reviewed using appropriate screening instrument or test and documented well.

Physical Examination

Assessment from a focused physical examination should be documented. This includes patient’s height, BMI (initial AWV only), weight, blood pressure and other measures. You should document the assessment and detection of any kind of cognitive function impairment (Alzheimer’s or other forms of dementia) through observation and/or screening procedures.

Screening Schedule

Document an age-appropriate screening schedule of preventive services for the patients to receive from Medicare in the next five to ten years based on recommendations from the U.S. Preventive Services Task Force. The patient’s health status and screening history should be recorded as well.

Risk Factors

It is required to document a list of current risk factors of patients including mental health, their conditions and recommended treatment options along with their associated risks and benefits.

Personalized Health Advice

Document the personalized health advice along with the referrals for health education to promote wellness such as weight loss increased physical activity, smoking cessation, fall prevention, and improved nutrition. The preventive counseling services provided can also be mentioned.

The documentation requirements for initial and subsequent AWVs are almost the same. You have to just update the health-risk assessment, medical and family history, list of current medical providers and suppliers, written screening schedule from previous wellness visits, list of risk factors and conditions and the care provided currently or recommended during subsequent AWVs.