As you know, quality health care begins with an Annual Wellness Visit (AWV). The visit serves a dual purpose: health maintenance and disease prevention.
Here’s a checklist of what should be included as a part of an AWV:
- Assess current medical conditions
- Complete appropriate lab work
- Address preventative care
- Review medications
- Promote a healthy lifestyle
AWVs provide an opportunity to address the many important preventive care needs including childhood/adult immunizations and cancer screenings (breast, cervical, and colorectal). They can also be used to evaluate for fall risks, substance use, frailty, and cognition. Annual wellness visits should include the documentation of all active diagnoses with a specific and current medication treatment plan. All active diagnoses should be submitted on the claim to the highest specificity.
TIP: For older adults (age 66 and up), this is also a great time to start a conversation regarding advance care planning, assessing pain and functional status, and conducting a comprehensive medication review.
Annual Wellness Visit (AWV) vs. Comprehensive Physical Exam (CPE)
Common misconceptions arise around whether a CPE can be done at the same time as an AWV. Included below are some of the key differences between the two.
Annual Wellness Visit
- Face-to-face visit to complete a prospective risk assessment and develop a treatment plan.
- Schedule for preventative screenings.
- Test for cognitive wellness, e.g. look for signs of memory loss, dementia, frailty, and fall risk.
- Document patient’s health risk factors and treatment options and offer personalized health advice.
Comprehensive Physical Exam (CPE)
- Face-to-face, in-person visit that helps you assess your patient’s overall health and well-being to best support their ongoing health. Also, to learn whether patient is suffering from health problems and determine next steps for treatment.
- Perform lung, head and neck, abdominal, heart, joint, and neurological exams.
- Check reflexes and vital signs.
- Take urine and blood samples and submit for lab testing.
For both Annual Wellness Visit and Comprehensive Physical Exam
- Review medical and family history.
- Take routine measurements such as for height, weight & blood pressure.
- Create or update list of medical providers and prescription drugs.
- Assess risk factors for preventable disease.
Billing Tips:
CPE may be completed during same visit as AWV.
AWV and problem-oriented evaluation and management (E/M) service can be performed during same visit if needed:
- Medical documentation must show E/M service is significant and separately identifiable; Modifier 25 should be appended to E/M code.
Download Annual Wellness Visits
Annual Wellness Visit Form (AWV) and Coding Guide
Use our AWV template to document your patients’ Annual Wellness Visits (AWVs) and to develop personalized prevention plans to help keep them healthy.
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Our Case Managers can:
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