Claims Documentation for Annual Wellness Visits

September 2nd, 2014 /
Shani Yellin
/ 4 Min Read

Medicare covers a yearly appointment for patients to discuss their preventative care with their doctor and to create and assess preventative measures for the year, known as the Annual Wellness Visit (AWV). Components that can make up a wellness visit include history, assessment, cognitive function, screening schedule, risk factors, and personalized health advice. Annual wellness visits have specific documentation requirements, and it’s important to learn their specific components.

Annual Wellness Visit Rules and Components

Physicians are often obligated to provide annual 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. There are also templates available to Occupational Health visits for employer-provided health coverage.

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 is not a complete head-to-toe physical exam. This should be properly explained to the patient as early as possible, preferably during the initial phone call between the patient and the 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 Medicare.

Practitioners should mark AWV appointments clearly to make sure the correct paperwork is filled out and the right documentation template is used. While this may require additional staff training, it pays off in the long run. Clarifying patient visits will help to improve the patient-provider relationship and ensure claims are submitted correctly. For more details about AWVs, read The ABCs of the Annual Wellness Visit published by the CMS.

EHR Software Optimization of Annual Wellness Visits

PrognoCIS EHR makes AWVs simple and easy. The practitioner can set up patient reminders, determine patient eligibility checks, and carry out AWV documentation, all in the EHR. This enables physicians to delivers more AWV so that more patients can create their preventative care measures for the year, ensuring they get the best care for their unique requirements.

In addition to AWVs, PrognoCIS EHR provides specific Occupational Medicine templates, forms, and workflow. One of the most powerful features of our software is embedded Case Management. It is integrated both clinically and financially at the accident (or ‘case’) level which is invaluable to W/Comp, Auto, or any other injury-oriented practice (Occupation & Environmental, Pain Management, Neurology, Orthopedic, etc.).  To understand how some of our largest clients benefit from using PrognoCIS, please review our Occupational Health Case Study.

Patient Reminders are another way PrognoCIS helps practices stay focused on what’s happening in the clinic by allowing automation to assist in patient engagement, namely, getting them to their appointments on time.  Additional details about this simple to use the feature are available on the website’s Faxing/Texting page.

And, to ensure patients are covered before and after their wellness visit,  a practice may want to learn more about eligibility checks. We provide insight for this and five other claim related features in our ready-to-view webinar archive: “6 Hidden Gems to Resolve Denied Medical Claims

If you’re already a PrognoCIS member and wish to request adding this or other productivity features to your EHR software, fill out the form on our Contact Us page, or call our phone number on the top left corner of the website.

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