Documentation Requirements for the Medicare Annual Wellness Visit

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Doctor Reading Medical Documentation
by Lucy Lamboley

The documentation requirements for the Medicare annual wellness visit (AWV) serve multiple purposes. Most importantly, documentation is critical to maximizing the value of the Medicare AWV to patients. As AARP notes, the Medicare AWV is "… designed to promote the use of preventive care, identify health risks, and plan for future healthcare needs." In addition, the Medicare AWV is an opportunity for patients to meet with providers who can also deliver or schedule preventive services, such as vaccinations and cancer screenings.

Meeting documentation requirements for the Medicare annual wellness visit is also critical for receiving reimbursement. If a provider fails to complete documentation requirements, it increases the likelihood of a claims denial, which will delay payment and grow the associated costs (e.g., staff time, reprinting of documentation) of billing for the service.

Finally, completing documentation requirements for the Medicare annual wellness visit is essential for avoiding non-compliance penalties from audits. The Centers for Medicare & Medicaid Services cite that insufficient documentation issues result in around 60% of improper payments. Such penalties can result in revenue loss for a practice, exclusion from Medicare, or even criminal liability in egregious cases.

While the COVID-19 pandemic has made it difficult for physicians to deliver many services to their patients, one could argue that it is easier now to perform the annual wellness visit than it was before the health crisis. The AWV is included in the telemedicine waiver and is relatively easy to provide via telehealth. Furthermore, in late April, Medicare waived the video requirements to permit telephone-only telehealth for many services, including the AWV. Physicians that choose to provide the AWV virtually, either via video or audio, must still complete all documentation requirements. 

To help ensure your patients receive the best Medicare annual wellness visit experience possible and your practice receives full reimbursement — and avoids giving any of it back — for provision of the service, let's review documentation requirements for the Medicare annual wellness visit. We'll break these out by the initial AWV and subsequent AWVs.

Documentation Requirements for Initial Medicare Annual Wellness Visit

The documentation requirements for the initial Medicare annual wellness visit are as follows:

  1. Health risk assessment. The health risk assessment (HRA) must be completed by a beneficiary or healthcare provider before or during the annual wellness visit encounter. At a minimum, the HRA should include demographic data; self-assessment of health status; psychosocial risks; behavioral risks; activities of daily living (ADLs), including dressing, bathing, and walking; and instrumental ADLs (IADLs), including shopping, housekeeping, managing medications, and handling finances. Note: If you are looking for help on how to guide your patients through the HRA, read this blog.
  2. Medical and family history. When documenting a beneficiary's medical and family history, work to capture as much detail about the medical events of the patient's parents, siblings, and children, including hereditary or high-risk conditions; past medical and surgical history; and medication use, including prescriptions, over-the-counter drugs, vitamins, and supplements. Considering the current opioid crisis, healthcare providers are encouraged to discuss, assess, and document any opioid use.
  3. Current providers and suppliers. This list should include all current healthcare providers and suppliers that regularly provide care to the beneficiary, such as primary care physicians, specialty physicians, chiropractors, acupuncturists, pharmacies, herbalists, and therapists. 
  4. Measurements. Capture essential, routine measurements. These would include height, weight, body mass index/waist circumference, blood pressure, and any other measurements you determine to be appropriate based on the medical and family history noted earlier. Note: While the capturing of such measurements may make the Medicare annual wellness visit seem like an annual physical exam, the two services are quite different, as we discuss in this blog.
  5. Cognitive function. Screen for cognitive function (including diseases such as Alzheimer's and other forms of dementia) via direct observation and document the findings. Do so while taking into consideration information from beneficiary reports and any concerns raised about the patient by family, friends, caregivers, etc.
  6. Potential risk factors for depression. Using a standardized depression screening test (such as these provided via the Substance Abuse and Mental Health Services Administration), review a beneficiary's potential risk factors for depression. This should include current or past experiences with depression or other mood disorders.
  7. Functional ability and safety. Via direct observation of a beneficiary and/or leveraging questions from screening questionnaires, assess a patient's functional ability and safety, considering at least the ability to successfully perform ADLs, fall risk, hearing impairment, and home safety.
  8. Written screening schedule. If healthcare providers miss the mark on documentation requirements, there's a good chance it occurs here. Providers are expected to produce a written preventive screening and services plan for the beneficiary's next 5-10 years. This is an integral part of the personalized prevention plan of service (PPPS). We review the PPPS requirements and provide several recommendations on how to improve the development of a personalized prevention plan in this blog. Of particular note is the following from the column:

    "Within the regulations is the expectation that patients will be 'furnished' with the personalized prevention plan and advice. While furnished is not specifically defined, it has been interpreted to mean either a physical copy of the PPPS handed to the patient upon completion of the AWV or a copy placed into a patient's active health portal account."
  9. Risk factors and conditions. Generate a list of risk factors and conditions for which intervention — primary, secondary, and/or tertiary — are recommended or underway. Include mental health conditions, including depression, substance use disorder, and cognitive impairment; any risk factors or conditions identified through the initial preventive physical examination (also known as the IPPE or "Welcome to Medicare" preventive visit); and treatment options and their associated risks/benefits.
  10. Health advice and referrals. Healthcare providers should document and share personalized health advice with beneficiaries. This would include referrals to health education and/or preventive counseling services and programs aimed at lifestyle interventions to promote wellness in areas such as weight loss, increased physical activity, smoking cessation, fall prevention, and improved nutrition.
  11. Advance care planning services (upon request). If a beneficiary is comfortable with it, healthcare providers should discuss advance care planning services and document what was discussed. Topics to cover include future care decisions that must be made, how patients can inform others about care preferences, caregiver identification, and explanation of advance directives (which may involve completion of forms).

Documentation Requirements for Subsequent Medicare Annual Wellness Visits

The documentation requirements for subsequent annual wellness visits after a beneficiary's first AWV are as follows:

  • Update the HRA
  • Update the beneficiary's medical and family history
  • Update the list of current healthcare providers and suppliers
  • Document the routine, essential measurements
  • Assess cognitive function
  • Discuss depression and risk factors
  • Update written screening schedule
  • Update risk factors and conditions for which interventions are recommended/underway
  • Update the prevention plan of service, including personalized health advice and referrals to health education and/or preventive counseling services or programs, as appropriate
  • Review/discuss advance care planning services, at the patient's discretion

Properly Completing Documentation Requirements for the Medicare Annual Wellness Visit

While it is important to understand the documentation requirements for the Medicare annual wellness visit (initial and subsequent), you must also follow the rules dictating who can "provide" and who can "perform" the AWV. These are two different concepts, as we discussed in this blog. Understanding these differences is important to further avoid improper billing, recovery audits, and even possible criminal liability.

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