Claims Documentation for Annual Wellness Visits

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TL;DR
Annual wellness visit (AWV) documentation generally differs from other preventative physical exams or checkups. Components that can make up a AWV include history, assessment, cognitive function, screening schedule, risk factors, and personalized health advice.

Annual Wellness Visit Rules

Physicians often must provide annual wellness visits (AWVs) and preventive visits for Medicare patients. In order to ensure that a claim will withstand a Medicare audit, different templates need to be used for each type of visit. For example, the documentation for the initial or subsequent AWV cannot resemble that of a preventive physical exam.

The rules for AWVs are very different from the rules for preventive visits. Unlike AWVs, preventive visits aren’t covered by Medicare. Preventive physical documentation won’t meet the requirements of an AWV because measuring BMI and depression are the only elements that the two visits have in common.

The various components that make up an AWV include:

  • History: The patient’s medical and family history.
  • Assessment: The patient’s height, weight, BMI (initial AWV only), blood pressure and other appropriate measures based on the patient’s history.
  • Cognitive function: Assessment and detection of possible cognitive function impairment through observation and screening.
  • Screening schedule: A schedule of recommended, age-appropriate screenings for the patient to receive in the next five to ten years based on the patient’s current health, screening history, and recommendations from the U.S. Preventive Services Task Force.
  • Risk factors: A list of current risk factors for conditions, treatment options, risks and benefits.
  • Personalized health advice: Referrals to health programs such as weight loss and nutrition programs.

Contrary to popular belief, an AWV isn’t a complete head-to-toe physical exam. This should be properly explained to the patient as soon as possible, preferably during the initial phone call between the patient and provider.

An AWV, preventive physical, and an evaluation and management (E/M) service can all be billed on the same date. However, documentation must support each individual service. For the initial or subsequent AWV, all components must be provided and documented to bill to Medicare.

Appointments should be clearly marked for AWV to make sure the correct paperwork is filled out and the right documentation template is used. While this may require additional staff training, it’ll pay off in the long run. Clarifying patient visits will help to improve the patient-provider relationship and ensure claims are submitted correctly.

Author: Lauren Daniels

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