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New Annual Wellness Visit: Boon or Trap?

Understand the requirements for appropriate reimbursement.

By Stephen C. Spain, MD, FAAFP, CPC
As required by the Patient Protection and Affordable Care Act (PPACA), the Centers for Medicare & Medicaid Services (CMS) recently amended the Code of Federal Regulations (CFR) to include an annual wellness visit (AWV) for Medicare beneficiaries. The revenue for this service is significant, and it may be performed in addition to an evaluation and management (E/M) service at the same visit; therefore, it is in a providers’ financial interest to offer this new service. Coders must understand the requirements and nuances of the new benefit, so charges can be submitted properly for appropriate reimbursement.

AWV Isn’t a Typical Annual Physical

This AWV is “free” to Medicare patients, in that no co-pay or deductible will apply. Jurisdiction Medicare administrative contractors (JMACs) are reimbursing the initial AWV at approximately $150, and the subsequent AWV at roughly $100. This reimbursement should ensure that patients are offered the benefit.
The AWV is not the annual physical examination that most physicians were trained to perform, however. Physicians who complete a routine annual checkup and expect to submit this service for payment under the new benefit rules will fall far short of meeting the AWV requirements. The AWV contains little “hands on” examination, but when properly performed will help to identify important health risks and ensure Medicare patients receive the screening services they are due.
The intent of the initial AWV is to assess nine areas:
1. Establish the patient’s past family, medical, and surgical history
2. Document the patient’s current medications and supplements, to include specifically calcium use and multi-vitamin use
3. Generate a list of the patient’s current health care providers, including home health agencies and durable medical equipment (DME) providers
4. Measure the patient’s vital signs and body mass index (BMI)
5. Assess the patient’s risk for depression
6. Assess the patient’s cognitive ability
7. Assess the patient’s risks for falls or injury
8. Determine and recommend the preventive health services that are due
9. Document the identified health risks and provide advice and referral, as appropriate and indicated, for these risks
As originally proposed, the AWV also included counseling for end-of-life planning. This “voluntary advance care planning” provision formed the foundation of the ballyhooed “Death Panel” criticisms directed against the PPACA. Under pressure from congress and the public, CMS notified providers on Jan. 10, 2011 that it had rescinded this requirement.

Tip: The interview format of the AWV involves asking a lot of direct, personal questions that may make some patients uncomfortable. You may wish to notify patients beforehand that their visit will be different, and explain the reason behind the changes in the usual encounter format. The sample letter shown in Figure A provides one example of how a practice might accomplish this.

Meet and Document Screening Specifics

The Medicare Benefit Policy Manual, chapter 15, section 280.5, requires that depression screening be  “based upon the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national professional medical organizations.”
This can be interpreted that a standardized screening instrument must be administered and scored, fully and properly. Providers should look at several of these, such as the MacArthur Initiative on Depression’s PHQ-9, or the Beck’s Depression Inventory. Sample PHQ-9 forms are widely available on the Internet. There are other instruments available; whichever is selected, however, must be administered in its entirety and meet the standard of being “recognized by national professional medical organizations.”
In contrast, the rules state that the evaluation to assess fall risk may be “based on direct observation or the use of appropriate screening questions or a screening questionnaire …” Cognitive evaluation screens similarly may be “based on direct observation with due consideration of information obtained by way of patient reports, concerns raised by family members, friends, caretakers, or others.” It’s a good idea to incorporate a few components each from standardized Fall Risk and Cognitive Assessment tools into the AWV documentation. For example, documentation of a modified “Get Up and Go” test and a few points of the Mini Mental Status exam would meet the requirements.
When the evaluation is completed, there must be documentation that the results and identified risks were presented to the patient. Documentation of risk counseling and assessment of preventive services that are due, as well as a schedule of services due over the next five to 10 years, also is required. The patient must receive a written copy of the findings and recommendations.

Requirements Differ for Subsequent Wellness Visits

The subsequent AWV requires a lesser evaluation than the initial AWV, as follows:
1. Update the patient’s past family, medical, and surgical history.
2. Update the list of the patient’s current health care providers.
3. Measure the patient’s vital signs and BMI.
4. Reassess the patient’s cognitive ability.
5. Update the preventive health services schedule developed at the initial AWV.
6. Update the list of risk factors for which intervention is recommended.
7. Document the identified health risks, and provide advice and referral, as indicated, for the identified risks from both this encounter and the initial AWV.
The most significant difference between the initial and subsequent AWVs is that the latter does not include depression or fall risk screenings. These are relatively easy to complete as part of the evaluation, however, and providers would be well advised to perform and document initial and subsequent AWVs in a similar manner.
By requirement, the patient must receive a written summary of the risk assessment and recommendations. This summary must include a preventive care screening schedule for the next five to 10 years, and should document counseling and referrals, as necessary, for all the health risks identified in the AWV. The record should document that the points of the summary were reviewed with the patient, and that the patient received a copy of the summary.

Timing Is Everything

The initial preventive physical examination (IPPE) or “welcome to Medicare exam,” the initial AWV, and all subsequent AWVs must occur at least one year apart. The IPPE also must take place within six months of the patient’s Medicare eligibility. Providers must pay attention to the timing of these evaluations to ensure proper reimbursement. Patients are eligible for only one AWV per year, so it will be important to determine whether the patient might have had an AWV from another provider in the previous 12 months.

A Win-Win for Patients and Providers

The AWV will be a significant source of revenue for providers. As aforementioned, CMS also specifically has allowed distinct and separate E/M services to be provided and billed at the same encounter. As providers learn of the significant revenue available from these evaluations, there likely will be a stampede of interest in providing the AWV.
If undertaken without careful forethought and planning, billing for the AWV could be a trap waiting to ensnare your providers. When correctly implemented, however, the AWV will help to improve the health and wellbeing of many elderly patients. As coders, we can help shoulder the responsibility of seeing that the key elements of the AWV are provided before the service is submitted for payment. By understanding and explaining the proper application of CMS rules in the provision of the AWV, coders can help ensure this unique encounter is a win-win for the provider team and the patient.

Figure A: Sample Annual Wellness Visit Notification Letter

Dear Patients and Friends,
Recently, the details of the new yearly physical examination for Medicare beneficiaries were unveiled by the federal Centers for Medicare & Medicaid Services (CMS). However, this new benefit is not exactly what most of us would consider an annual physical exam. It is, rather, more of an “evaluation.” Medicare acknowledges as much, in that they have renameda the benefit the “annual wellness visit.”
The purpose of this letter is to explain this benefit to you so you will understand how these government-mandated changes will affect your annual visit.
The new “annual wellness visit” is intended to assess:

  • The patient’s risk for depression;
  • The patient’s cognitive ability;
  • The patient’s risks for falls or injury;
  • Generate a list of the patient’s current health care providers; and
  • Determine
  • and recommend the preventive health services that are due.

There is virtually no physical examination required, and the encounter focuses on interviewing and updating portions of your medical history.
It is important that we implement this new visit. When properly and thoughtfully undertaken, this benefit should help identify patients at risk for serious health issues. Medicare also has begun keeping a scorecard to see how well physicians are providing certain services, which likely will soon include this new benefit. Doctors who don’t provide this new service could be ranked as “underperforming” by Medicare. This may lead to financial and administrative penalties. To comply with the new requirements, our office must make changes in how we handle your annual visit.
For most of you with stable chronic health conditions, it is only necessary to be seen two or three times a year. To perform this new benefit as a separate service, an additional trip to the office each year would be required, and many patients would find this inconvenient. To avoid an extra office visit, we plan to include the new benefit at your annual examination.
This new visit format will mean that the nurse will spend more time with you completing the required screening questionnaires. Accordingly, the doctor’s time with you will be focused on an examination pertinent to your continuing health issues, explaining the results of the screening tests, and going over the status of your preventive care screenings.
When you come in for your annual wellness visit, the staff will go over a series of questions with you. These are not random questions, but are widely accepted screening instruments for identifying depression and dementia risks, and safety hazards. You may find this process silly or perhaps even insulting, but please be patient and understanding as we try our best to implement these mandates in the required manner.
You can review the wellness visit requirements at this web address: In addition, we will keep copies of the visit requirements, as well as the screening questionnaires, at our office for your review.
We plan to implement these changes in <<month>>. If you do not want to participate in the new annual wellness visit, you will need to sign a waiver to that effect. If you choose to opt out of the new benefit, we will see you for the “old” style annual physical exam, but this would likely be an out-of-pocket, uncovered expense for you.
Change is often difficult, but we are hopeful we can implement this new requirement in a way that is not disruptive to our primary goal of working to ensure your health and well being. We thank you in advance for your patience and understanding.
Yours truly,
<<Provider Name>>

Dr. Spain has been engaged in the full time practice of family medicine for over 25 years. In 1998, he founded Doc-U-Chart, a practice management consulting firm specializing in medical documentation. Dr. Spain can be reached at


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