Making the most of the Medicare Annual Wellness Visit

Alison M. Mancuso, DO, UMDNJ-SOM, Family Medicine, 42 E Laurel Road, Suite 2100A, Stratford, NJ 08084.

E-mail address: brennaam@umdnj.edu.

This article was designed to be viewed and distributed as a PDF. Please download the PDF for easiest reading.            

‌Introduction

Among many changes made to the current healthcare system, the Patient Protection and Affordable Care Act (ACA) now provides coverage for “Wellness Visits” for Medicare part B beneficiaries. The purpose of the Annual Wellness Visit (AWV) is to help Medicare patients in maintaining health and preventing or slowing chronic disease processes along with encouraging healthy lifestyle habits. The wellness visit encourages patients to take an active role in their healthcare.

There are a little more than 45 million Medicare enrollees across the country which represents approximately 16% of the total United States population.1 This number is only expected to increase as the “Baby Boomer” generation enters Medicare eligibility. This volume of Medicare beneficiaries makes it important for family physicians and other primary care providers to be aware of the services that are available through Medicare insurance plans. The department of Health and Human Services reported in a press release that approximately 1.35 million Medicare beneficiaries took advantage of the AWV in the first 6 months of 2012.2 This leaves more than 43 million beneficiaries who have not taken advantage of this preventative service, which leaves a gap in preventative care in this population. This is an important point in the era of quality improvement and payments and incentives reflecting high-quality care.

The AWV is a covered service of all Medicare part B participants, provided they meet certain eligibility criteria. Each beneficiary qualifies for one “Welcome to Medicare” or “Initial Preventive Physical Examination” (IPPE) service within the first 12 months of Medicare enrollment. During this visit, the provider may order a screening abdominal ultrasound in men with a smoking history to rule out abdominal aortic aneurysm. This service is only covered under IPPE during the first 12 months of Medicare enrollment. The AWV is covered as long as the patient is outside of the first 12 months of Medicare enrollment and it has been 11 full calendar months since their IPPE or previous AWV. Medicare distinguishes between the first time a patient gets the AWV and subsequent AWVs. Requirements for each visit type are described subsequently and in Table 1. The AWV is not considered to be a routine physical examination by Centers for Medicare and Medicaid Services (CMS), as Medicare does not cover routine physical examinations.

The wellness visit is available to Medicare beneficiaries at no out-of-pocket cost (ie, no copayment, deductible, or coinsurance payment). The ACA also increased Medicare

Table 1 Eligibility requirements for AWV Visit type Eligibility requirements

Initial annual wellness Patient enrolled in Medicare visit for 412 mo

IPPE was either not completed, or was 411 mo ago

Subsequent annual Patient has had initial annual wellness wellness visit visit previously

Patient’s last annual wellness visit was 411 mo ago

Table 3 Requirements for the initial Medicare wellness visit

History

Complete medical and surgical history (including: illnesses, hospitalizations, allergies, etc)

Complete medication and supplement list

Examination

Counseling

Height, weight, and Written screening

BMI (or waist circumference if appropriate)

schedule of USPSTF and ACIP

recommendations

Blood pressure measurement

Complete listing of Cognitive specialty evaluation providers and

medical suppliers

Family history including parents, children, and siblings

Depression screening

List of risk factors and conditions with recommended interventions

Personalized health advice and referral to health education or community-based prevention programs if appropriate

Functional ability assessment (hearing, activities of daily living, home safety, fall prevention, etc)

BMI ¼ body mass index; ACIP ¼ Advisory Committee on Immunization Practices.

‌payments to 100% for preventative services with recom- mendation grades of A or B from the United States Preventive Services Task Force (USPSTF). Four preventa- tive services do not meet USPSTF A or B standard but are still covered at a possible cost to the beneficiary: digital rectal examination for prostate cancer screening, glaucoma screening, diabetes self-management training, and barium enema for colorectal cancer screening. These 4 tests may be subject to a copayment, coinsurance, or deductible payment. An AWV may be provided by a medical professional (ie, MD, DO, Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist) or another health professional such as a health educator, registered dietician, nutrition professional, or other licensed health professional. Health Professionals should be working under direct supervision of the physician and be in compliance with state regulations regarding the scope of their licensure.

Table 2 Helping patient prepare for an annual wellness visit

Patients should bring the following information to their wellness visit:

Previous medical records: Vaccination records, hospital discharge paperwork, etc

Family health history: Detailed history for parents, siblings, and children

Medication list: All prescription medications, vitamins, and supplements

Provider list: Names of all specialists and other medical providers, including home care providers

Medicare differentiates between a patient’s initial AWV and subsequent AWVs. To qualify for an initial AWV, a Medicare beneficiary must have been enrolled in Medicare for more than 12 months and must NOT have had their “Welcome to Medicare Physical (IPPE)” service within the past 12 months.3 The AWV has 3 components that are included: History, Patient Assessment, and Orders or Counseling. Table 3 lists the requirements for each component.‌

‌History component

The history component of the initial AWV must contain a completed Health Risk Assessment (HRA). This is a new requirement that became effective January 1, 2012. According to the ACA, the HRA should identify chronic diseases, injury risks, modifiable risk factors, and urgent health needs of the patient. The HRA can be administered in multiple ways including a paper survey, telephone survey, or Web-based program. This can take place during the encounter with the healthcare provider, prior to the visit or through community-based prevention programs.4 An HRA usually takes about 20 minutes to complete.

The CMS does not recommend or endorse any specific HRA. Several online and paper formats exist that could meet the CMS guidelines. The Centers for Disease Control and Prevention provides a sample HRA on its website.5 Appendix 1 demonstrates a sample HRA that was devised from the Centers for Disease Control and Prevention HRAs format.

‌The goal of the HRA is to improve health outcomes by identifying behaviors and modifiable health risks to continue disease prevention and health promotion. The HRA provides a starting point for a dialog between patients and physicians regarding health-related behaviors in the hope of reducing health-related risk factors. CMS currently has a study in process regarding the use of HRA and the effect on risk reduction. The study is scheduled to release results in 2013.

In addition to the HRA, a complete medical and family history is required during the initial AWV. This complete history is to include all illnesses, hospitalizations, surgeries, allergies, injuries and chronic diseases, and treatments. Patients should provide a current list of all medical providers and suppliers. A current list of all medications and supplements and vitamins is also included in the complete medical history. A family history of the patient’s parents, children, and siblings must be documented for all conditions, both hereditary and nonhereditary (Table 2).

Certain screening tests should be performed during the initial AWV, including a recognized depression screening tool. Providers should review the risk for depression, including any current or past experience with a mood disorder with the patient during the AWV. There is no particular depression screening instrument recognized by CMS for use in the AWV, so the provider may choose to use any screening tool as long as it is a nationally recognized instrument.

Screening should also take place for functional ability and safety. This can be accomplished by direct observation of the patient alone or in combination with appropriate screening questions on hearing impairment, performance of activities of daily living, home safety, and fall risk. Some of these questions may be addressed on the HRA and can be discussed further during the AWV. Again, there is no particular functional ability screening tool that is recom- mended by CMS to accomplish this screening.

‌Patient assessment

Because the AWV is not a physical screening examination by definition, the physical examination components of the AWV are limited. Each AWV patient should have the following examination items performed: blood pressure measurement, height, weight, body mass index or waist circumference, and cognitive examination. The provider should directly observe patient for signs of cognitive impairment or decline. The provider may elicit feedback and information from family members or caretakers present during the examination to aid in cognitive assessment.

An electrocardiogram (ECG) is not a covered service in the AWV. The only time a “screening” ECG is covered by Medicare is under the “Welcome to Medicare Physical (IPPE)” service during the first 12 months of Medicare enrollment. If an ECG is medically necessary during the AWV, the patient should sign an Advance Benificiary

Notice form as this service may not be covered. A copayment or deductible payment may also apply to an ECG in this setting.

Orders and counseling

yAAA screening only covered if referral is made from IPPE visit

Breast cancer screening (mammogram)

Well woman examination (Papanicolaou test and pelvic examination)

Intensive behavioral therapy Sexually transmitted

(IBT) (for cardiovascular infection (STI) screening disease) and counseling to prevent

STI

IBT (for obesity) Ultrasound for abdominal aortic aneurysm screeningy

ACIP ¼ Advisory Committee on Immunization Practices; DEXA ¼ dual-energy x-ray absorptiometry; DRE ¼ digital rectal examination; HIV ¼ human immunodeficiency virus; AAA ¼ abdominal aortic aneurysm.

nCertain tests without A or B USPSTF grading are covered by Medicare part B, but copayment may apply

Diabetes self-management training

Glaucoma screening*

HIV screening

(except DRE*)

Seasonal influenza vaccine and administration

Pneumococcal vaccine and administration

Hepatitis B vaccine and administration

Alcohol misuse screening and counseling

Adult depression screening

Colorectal cancer screening

(except barium enema*)

Tobacco use counseling in asymptomatic patients

Diabetes screening tests

Prostate cancer screening

Medical nutrition therapy (MNT)

Initial preventative physical examination (IPPE) (within 12 mo of Medicare enrollment)

Bone mass measurement (DEXA scan)

Cardiovascular screening blood tests (lipids, etc)

Table 4 Covered screening services

Medicare part B covered screening services 2012

Preventative services with USPSTF grade of A or B are covered, ACIP recommendations covered

During the AWV, the provider must provide each patient with a personalized written schedule for covered health screening services and immunizations. This document must use USPSTF and Advisory Committee on Immunization Practices standards, as this is how Medicare bases its coverage. The screening document should be an overview of screening tests available to the patient for the next 5-10 years. A list of covered Medicare screening tests is provided in Table 4. For the most up-to-date guidelines from the USPSTF and Advisory Committee on Immunization Practices, providers can visit http://www.ahrq.gov/clinic/ uspstfix.htm and http://www.cdc.gov/vaccines/acip/index. html.

‌The patient should also be provided with a written list of the conditions and risk factors for which treatment is being recommended to them. This includes all chronic diseases, mental health conditions, and treatment options. Associated risks and benefits should be included in this list where applicable. Some electronic health record programs provide a “Patient Instructions” handout which would fulfill this requirement if a list of medications and chronic conditions is included.

‌The provider must also furnish personalized health advice based on patient’s age and health status. This should include referrals for applicable health education and prevention programs, including community-based interven- tions to promote self-management and wellness, such as weight loss and physical activity programs.

The final requirement of the AWV is Voluntary Advanced Care Planning. The provider should give patient written or verbal information about preparing an advanced directive if the patient is receptive to this information. The patient may decline this portion of the AWV if they desire. The subsequent AWV draws upon the same information that was obtained in the initial AWV. The differences are

detailed in the next section.

‌Visit requirements: Subsequent AWV (G0439)

The subsequent AWV has different eligibility criteria than the initial AWV. To be eligible for the subsequent AWV, a patient must have already had an initial AWV. The patient becomes eligible for a subsequent AWV 11 full months after a previous AWV. The subsequent AWV essentially updates all information obtained during the initial AWV.

‌History

‌The provider must update the HRA, addressing demo- graphics, self-assessment of health, psychosocial risks, behavioral risks, and activities of daily living. Patients may complete the HRA document prior to the examination or during the physician visit. Medical and family history also need to be updated and documented. If no changes have occurred from last AWV, prior history can be used and documented. An updated list of providers should be included in documentation. If no changes exist, the prior provider list may be documented.

Examination

The physical examination only requires a weight and blood pressure measurement (height and body mass index calculation are NOT included in the subsequent AWV). The provider should also screen again for cognitive impairment by direct observation of the patient in conjunction with information provided by family and caretakers if available.

Orders and counseling

The provider should update the written screening schedule from the prior AWV. The patient should also be given an updated document with conditions, risk factors, treatments, and recommended interventions. Finally, the patient should be given personalized health advice and referrals as appropriate for wellness-related behaviors including weight loss, smoking cessation, fall prevention, nutrition, etc.

An example template of the AWV is provided in Appendix 2.

Preparing to provide AWVs

There are several issues that arise with readying offices to schedule Medicare AWVs. Office staff should be trained on what the eligibility requirements for wellness visits are and should be prepared to alter scheduling practices to provide extra time for the AWVs.

Scheduling staff needs to be aware of who might qualify for the AWV. Staff should ask a few simple questions that will help determine the kind of visit a Medicare patient needs. Figure 1 provides a sample script with the important points to ask when scheduling a patient for the AWV. The important information to obtain for scheduling is whether the patient qualifies for an initial or subsequent AWV based on the date of their Medicare enrollment and prior Wellness Visit history and whether the patient has any other health concerns that would not be covered by the AWV.

Verification of prior Medicare Wellness Visits or IPPE or both can be obtained through the electronic Eligibility Response Transaction Report 271 for offices that participate in electronic eligibility verification for Medicare patients. Other methods for obtaining verification can be solicited from each particular Medicare service provider.6

AWVs may need more time than a typical office visit. Because of the time needed to review health history and provide personalized counseling, it is suggested this visit be scheduled for approximately 40 minutes. Utilization of templates in electronic medical record software may help streamline the multiple requirements of the AWV and make the visit more time efficient. Having patients complete the HRA questionnaire prior to coming for their visit will also help with time efficiency.

Nursing and medical assistant staff can be utilized to help complete portions of the visit before the patient sees the provider. In a recent article, Arnold Cuenca describes a visit structure that may be helpful for time management with these visits. The staff completes a previsit evaluation, where they identify what the patients require for the visit, including vaccines, ECG, etc. This is usually completed the day before the actual patient visit. When the patient actually presents to the office, he or she has a 2-step visit, where the patient sees the nurse or MA first and then the provider second. Staff can administer the HRA, review and update the patient’s medical, social, and family history, and update the medication list. Staff can also obtain vital signs, complete a functional ability assessment, and administer a depression scale and mini–mental status examination. Once this portion of the visit is complete, the physician or provider can review the information obtained and examine the patient. The provider can then provide a written summary of the visit, with preventative services checklist and other recommended care. Cuenca estimates that this structure takes about 30 minutes for the nursing staff and about 15-20 minutes for the provider to perform.7

‌Billing and coding

Proper billing and coding techniques are required to be successfully reimbursed for the AWVs through Medicare. Table 5 demonstrates proper codes and reimbursement rates for each wellness visit. To avoid payment denial due to duplication of services, it is important to verify that the patient is indeed eligible for the AWV service. The CMS recommends contacting your Medicare Administrative

Contractor to find out how to best determine patient eligibility. Certain contractors will be able to provide physician offices with eligibility information over the internet.

The AWV coverage is the same no matter which Medicare or Medicare advantage plan the patient has. If the patient has Medicare as a secondary insurance, Medicare will cover any part of the AWV that is not paid for by the primary insurance payer.

There is no difference between new and established patients when billing for AWVs. Any ICD-9 code may be associated with the Healthcare Common Procedure Coding System codes used for billing AWVs.

AWV encounters are reimbursed at a higher rate than regular office encounters. For “nonfacility”-based encoun- ters (ie, office based, nonhospital or facility based), the initial AWV is rated at 4.89 relative value units (RVU) which equates to an average national payment of $166.44, where the subsequent AWV is rated at 3.26 RVU which

equates to an average national payment of $110.96. For comparison, a 99,214 visit is rated at 3.1 RVU which equates to an average national payment of $104.16. Payments vary based on region and local Medicare Administrative Contractor.8

‌When a nonphysician provider, such as a nurse practitioner or physician assistant, provides the AVW service, the service can be billed under the nonphysician provider’s own provider ID number (instead of as an “incident-to” service in coordination with the supervising physician).

Residents may perform the AWVs without direct physician supervision under the primary care exception in the same way they can perform other Medicare-covered services.

Other medically necessary services may be provided at the same facility on the same day if the services are separate and distinct, and a modifier-25 is used. For example, a patient can have their AWV provided and on the same day have a problem-based visit to treat illness or improve functioning of the patient (99,212-99,215). It is important to note that no part of the AWV may be used to determine the level of the additional visit. Another example would be if the provider performed a breast and pelvic examination with Papanicolaou test (using codes G0101 and Q0091) on the same day as the AWV.

As with any service that may not be covered by Medicare unless certain criteria are met, an Advanced Beneficiary Notice form should be completed by patients prior to rendering the AWV and any additional services (eg, ECG, Breast Exam, and Papanicolaou test) rendered at that time. The patient may elect to defer this service and confirm eligibility if desired.

Conclusion

The Medicare AWV is an excellent opportunity to promote health and wellness in our senior population which continues to grow as more and more “Baby Boomers” approach Medicare enrollment. Knowledge of how to properly perform the AWV is important, as it helps maintain health in our aging population and is a great revenue for our practices. There is a significant gap in the amount of Medicare enrollees (45 million) and those who have completed an AWV (1.35 million). Primary care physicians should inform their patients that these services are available and encourage patients to take advantage of this covered benefit. The tools provided in this article will help practices successfully incorporate the AWV into their day-to-day visit types.

‌Appendix 1. SAMPLE Health Risk Assessment (HRA)‌

Note: There is not one specific Health Risk Assessment tool that is endorsed or required by Medicare. This is a sample of a health-risk assessment that could be used.

Dear Patient,

The following questions will help us assess your current health status. Please answer each question to the best of your ability. Some questions may not apply to you. If you are unsure about a question, we can discuss it at your visit in more detail. We will review the entire questionnaire at your Wellness Visit. Thank you for taking an active role in your healthcare!

Patient Name:                                            Date of Birth:                       

Demographic Information

1. What is your age?

   1. 65-69

   2. 70-79

   3. 80þ

2. Are you male or female? (Circle)

3. What is your race? (Circle all that apply)

   1. White

   2. Black or African American

   3. Asian

   4. Native Hawaiian or Pacific Islander

   5. Native American or Alaskan Native

   6. Hispanic or Latino

   7. Other

      Your Mood

4. In the past two weeks how often have you felt depressed, down or hopeless?

   1. Not at all

   2. Some of the time

   3. Most of the time

   4. Almost all of the time

5. In the past two weeks, how often have you had decreased interest or pleasure in doing things?

   1. Not at all

   2. Some of the time

   3. Most of the time

   4. Almost all of the time

6. In the past two weeks, have your feelings caused you distress or interfered with your ability to get along with your family or friends?

   1. Yes

   2. No

7. In the past two weeks, have you felt anxious, nervous or edgy?

   1. Not at all

   2. Some of the time

   3. Most of the time

   4. Almost all of the time

8. In the past two weeks, have you been unable to stop or control your worrying?

   1. Not at all

   2. Some of the time

   3. Most of the time

   4. Almost all of the time

9. How often is stress a problem for you in handling your responsibilities in life?

   1. Not at all

   2. Some of the time

   3. Most of the time

   4. Almost all of the time

   
   

   Your Social and Emotional Support

10. How often do you get the social and emotional support you need?

    1. Always

    2. Usually

    3. Sometimes

    4. Rarely

    5. Never

11. During the past four weeks have you had someone available to help you if you physically needed/wanted help? (Example: someone to help with chores, someone to help with medications or self-care)

    1. Yes, as much as I needed

    2. Yes, quite a bit

    3. Yes, some

    4. Yes, a little

    5. No, not at all

       
       

       Your Pain

12. During the past two weeks, how much physical pain have you had?

    1. No pain

    2. Some pain

    3. A lot of pain

       Your Activities of Daily Living

13. Can you get to places that are not walking distance without help? (Example: by taking a bus, taxi or driving your own car)

    1. Yes

    2. No

14. Can you go grocery or clothing shopping without someone’s help?

    1. Yes

    2. No

15. Can you prepare your own meals without someone’s help?

    1. Yes

    2. No

16. Can you do your own housework without help?

    1. Yes

    2. No

17. Can you take care of personal care needs such as eating, bathing, dressing, and getting around the house without help?

    1. Yes

    2. No

18. Can you handle your own money without help?

    1. Yes

19. ​

    b. No

    Can you use the telephone without someone’s help?

    1. Yes

    2. No

    Your Safety

20. Are you having any difficulty driving your car?

    1. Often

    2. Sometimes

    3. Never

    4. I do not drive a car.

21. Do you always fasten your seat belt when driving/riding in a car?

    1. Nearly Always

    2. Sometimes

    3. Never

22. Have you been given any information about how to avoid safety hazards in your home?

    1. Yes

    2. No

23. In the past year, have you fallen more than twice?

    1. Yes

    2. No

24. Are you concerned or afraid that you could fall?

    1. Yes

25. ​

    b. No

    Do you feel safe in your current living situation?

    1. Yes

    2. No

    Your Personal Health Assessment

26. How would you rate your overall health?

    1. Excellent

    2. Very Good

    3. Good

    4. Fair

    5. Poor

27. How would you rate your overall mouth health—including teeth/dentures/etc?

    1. Excellent

    2. Very Good

    3. Good

    4. Fair

    5. Poor

28. Have you had any episodes of dizziness or falling when standing in past four weeks?

    1. Always

    2. Often

    3. Sometimes

    4. Seldom

    5. Never

29. Have you had any episodes of sexual problems in past four weeks?

    1. Always

    2. Often

    3. Sometimes

    4. Seldom

    5. Never

30. Have you had any episodes of trouble eating well in past four weeks?

    1. Always

    2. Often

    3. Sometimes

    4. Seldom

    5. Never

31. Have you had any episodes of tiredness and fatigue in past four weeks?

    1. Always

    2. Often

    3. Sometimes

    4. Seldom

    5. Never

32. Have you had your blood pressure checked within the past year? If so, was it:

    1. Low or normal (at or below 120/80)

    2. Borderline High (120/80 to 139-89)

    3. High (140/90 or more)

    4. Unsure

    5. I haven’t had my blood pressure checked in past year

33. Have you had your total cholesterol checked within the past year? If so, was it:

    1. Desirable (Less than 200)

    2. Borderline High (200-239)

    3. High (240 or more)

    4. Unsure

    5. I haven’t had my cholesterol checked in past year

34. Have you had your fasting blood glucose (sugar) checked in past year? If so, was it:

    1. Desirable (below 100)

    2. Borderline High (100-125)

    3. High (126 or higher)

    4. Unsure

    5. I haven’t had my blood glucose checked in past year

35. If you are a diabetic, have you had your Hemoglobin A1C checked in past year? If so, was it:

    1. Desirable (o6.5%)

    2. Borderline High (6.5%-7.9%)

    3. High (48%)

    4. Unsure

    5. I haven’t had my A1C checked in past year

36. What is your height?     feet     inches

37. What is your weight?     pounds

    Your Sleep

    
    

38. On average, how much sleep do you usually get each night?       hours per night

39. Has anyone ever told you that you snore or stop breathing while you are sleeping?

    1. Yes

    2. No

40. In the past two weeks, have you felt sleepy during the daytime?

    1. Always

    2. Often

    3. Sometimes

    4. Rarely

    5. Never

       
       

       Your Nutrition

41. In past 7 days, how many servings of fruits/vegetables have you eaten per day? (Serving ¼1 cup fresh vegetables, 1 medium piece of fruit, ½ cup cooked vegetables)     

42. In past 7 days, how many servings of high fiber or whole grain foods have you eaten per day (Serving ¼ 1 slice of 100% whole wheat bread, 1 cup of ready-to-eat cereal, ½ cup cooked cereal, or ½ cup cooked brown rice or wheat pasta)     

43. In past 7 days, how many servings of fried or high-fat foods did you eat each day? (examples: fried chicken, fried fish, bacon, French fries, potato chips, foods made with whole milk, cream, cheese, or mayo)     

44. In past 7 days how many sugar-sweetened beverages (not diet) did you consume each day? (example: soda, juice, coffee, or iced tea with sugar)     

    
    

    Your Tobacco/Alcohol Use

    
    

45. In the last 30 days, have you used any tobacco containing product?

    1. Yes, smoked tobacco product

    2. Yes, used smokeless tobacco product

    3. No

46. If you have used tobacco in past 30 days, are you interested in quitting within next 30 days?

    1. Yes

47. ​

    1. No

       During past four weeks, how many alcoholic beverages (beer, wine, liquor) have you had?

       1. 10þ drinks per week

       2. 6-9 drinks per week

       3. 2-5 drinks per week

       4. 1 or less drinks per week

       5. No alcohol at all

    
    

    Your Exercise/Physical Activity

48. In the past 7 days, how many days did you exercise?       days

49. When you did exercise, how long did you exercise for?       minutes

50. What was the intensity of your exercise?

    1. Light (stretching, slow walking)

    2. Moderate (brisk walking, light swimming)

    3. Heavy (jogging, fast swimming)

    4. Very Heavy (fast running, stair climbing)

    
    

    Your Health Management

51. How often do you have trouble taking the medications you have been told to take?

    1. I don’t take any medications

    2. I always take my medications as prescribed

    3. Sometimes I take my medications as prescribed

    4. I rarely take my medications as prescribed

52. How confident are you that you can control and manage your health problems?

    1. Very confident

    2. Somewhat confident

    3. Not very confident

    4. I don’t have any health issues to manage

‌Appendix 2. Annual Wellness Visit Chart Template‌

Date of last Wellness Exam                    Medicare Eligibility Date:                

Gender:       If female: LMP/Date of Menopause              , Pregnancy Status (GxPx)           Do any language/communication barriers exist? YES/NO

If so, please describe:

Physician/Provider Signature indicates review of above:                                

Exercise Type/Amount:                                                           Occupation (or former if retired):                             

Home Environment: Private home Assisted Living Nursing Facility Other Physician/Provider Signature indicates review of above:                                

Part 3: Family History (indicate with a þ if positive history exists)

Physician/Provider Signature indicates review of above:                              

Dates:          

Location:          

Attending:        

Reason:              

Current/Past Medical Problem List

Dates:            

Location:            

Attending:          

Prior Surgical History

Medication List: Include OTC Supplements, Herbals, Vitamins, etc

Allergy List

Other Providers of Care

Physician/Provider Signature indicates review of above:                              

Part 4: Patient Assessment

Depression Screening

1. In past two weeks, has patient felt down, depressed or hopeless? YES NO

2. In past two weeks, has patient felt little interest or pleasure in doing things? YES NO

Functional Ability/Safety Screening

1. Get Up And Go Test: Was patient’s test unsteady or longer than 30 seconds? YES NO

2. Does patient need help with: telephone, transportation, shopping, preparing meals, housework, laundry, medication or money management? YES NO

3. Home safety: does patient home have grab bars in bathroom, handrails on stairs, adequate lighting, secured rugs? YES NO

4. Does patient have hearing difficulties? YES NO (if yes, perform hearing evaluation)

Cognitive Function Evaluation Mood/Affect:

Appearance:

Memory:

Family Member/Caregiver Concerns/Input:

Part 5: Patient Counseling/Referral for Preventative Services Checklist

**indicates service that may require copayment or deductible payment

‌References

1. The Henry J. Kaiser Family Foundation. Total Medicare beneficiaries by state 2012. Available at: http://www.statehealthfacts.org. Accessed October 2012.

2. HHS Press Office. More than 16 million people with Medicare got free preventative services in 2012. Available at: http://www.hhs.gov/news/press/ 2012pres/07/20120710a.html. Accessed November 2012 [Published July 2012].

3. Medicare Learning Network. Quick reference information: The ABCs of providing the annual wellness visit. Available at: http://www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProd ucts/downloads/AWV_Chart_ICN905706.pdf. Accessed October 17 2012 [Published January 2012].

4. Patient Protection and Affordable Care Act. Sections 4103–4105. Revised June 2010. Available at: http://housedocs.house.gov/energy commerce/ppacacon.pdf. Accessed October 2012.

5. Goetzel, RZ, Staley P, Ogden L, et al.: A framework for patient-centered health risk assessments—providing health promotion and disease prevention services to Medicare beneficiaries. Atlanta, GA: US Depart- ment of Health and Human Services, Centers for Disease Control and Prevention, 2011. Available at: http://www.cdc.gov/policy/opth/hra/. Accessed October 2012.

6. ‌Hughes Cindy. What you need to know about the Medicare preventive services expansion. Fam Pract Manag. 2011;18(1):22–25. [Accessed October 2012][Accessed October 2012]

7. ‌Cuenca E. Making Medicare wellness visits work in practice. Fam Pract Manag. 2012;19(1):11–16

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