Don’t Forget Wellness Visits: Components & Documentation Requirements
Medicare covers annual wellness visits (AWVs) that provide important opportunities for health care providers to assess health risks and help patients plan for Medicare preventive services (e.g., vaccinations and screenings for illnesses like cancer or diabetes), which can greatly reduce those risks.
Components of an AWV
The initial AWV is conducted once per lifetime, after a patient’s first year of Medicare enrollment. This visit is used to:
- Perform a health risk assessment (HRA), including collecting information on demographic data, health status self-assessment, psychosocial and behavioral risks, and activities of daily living
- Develop a personalized prevention plan (PPP), including referrals to educational counseling services to reduce health risks and to promote self-management and wellness
- Review current opioid prescriptions (if applicable) and screen for substance use disorders
Subsequent AWVs should be conducted annually, beginning 12 months after the patient’s initial AWV. These visits are used to review and update the HRA and PPP from the initial visit.
Watch this video to learn more about AWVs and other wellness visits available at no cost for eligible Medicare patients.
For details on each of the AWV components and documentation to maintain in the patient’s medical record, refer to the Medicare Wellness Visits Tool.
Successfully Submitting Claims for AWVs
Each Medicare wellness visit has a separate set of billing codes, and it’s important to understand the differences among them because billing the wrong visit or at the wrong time can result in denied claims. To reduce the number of denied claims, check out this printable chart that outlines which billing codes to use and when. This resource may also be a helpful tool for discussing wellness visits with your staff and eligible patients.