Medicare Annual Wellness Visit Checklist

Required — the visit is not what it claims to be without these

• Health risk assessment completedThe HRA is a required element. Send the pre-visit form, or record that it was completed in the office.
• Medical and family historyEstablish or update the medical and family history.
• Current providers, suppliers and medicationsList the clinicians, suppliers and medications involved in the patient’s care.
• Routine measurements (height, weight, BMI, BP)Height, weight, BMI and blood pressure are the routine measurements for the AWV.
• Detection of cognitive impairmentRequired at every AWV. Record how cognition was assessed and the conclusion.
• Depression / mood screenRecord the screen used and its result.
• Functional ability and safety (ADLs, falls, home, hearing)Functional ability and safety covers ADLs, falls risk, home safety and hearing.
• Written screening schedule for the next 5 to 10 yearsThe written schedule is a required deliverable the patient takes away.
• Risk factors and conditions, with interventionsList risk factors and conditions, with the interventions discussed.
• Personalized health advice and referralsPersonalized advice, with referrals to education or counseling where indicated.

Also document — the rest of the element set

• Advance care planning offeredOptional and at the patient’s choice, but recording that it was offered is good practice.

The element most often left hanging

Detection of cognitive impairment is required at every Annual Wellness Visit. When that screen is positive or borderline, the Cognitive Assessment and Care Plan (CPT 99483) is the visit it calls for. Last year US clinicians billed 10.5 million wellness visits and 127,353 cognitive care plans, so the screen happens and then the trail goes cold. Write the next step down while the patient is still in the room. What the 99483 involves →