Amanda.Kane
Contributor
I am looking for assistance with the Medicare Annual Wellness Visit and clarification on the element of "a list of risk factors" for the final section.
What if the provider documents the risk factors throughout the note (ex. in the history or the assessment)?
Would that fill the requirements or does it have to be an actual list?
Examples:
1.) The provider states that the patient has a risk stratification of 1 and currently is not at risk for anything. How could Medicare dock you if the patient has no risks and you completed everything else to qualify for the AWV?
2.) The provider takes a social history and discovers the patient is heavy smoker, he advises the patient to quit and gives him options for cessation. However, that is only in the history and not anywhere else in the note. Would that qualify for the risk factors requires in the AWV or does it have to be listed somewhere else in the note as well?
Please answer with links and documentation if available.
Thank you,
Amanda K, CPC, COBGC
What if the provider documents the risk factors throughout the note (ex. in the history or the assessment)?
Would that fill the requirements or does it have to be an actual list?
Examples:
1.) The provider states that the patient has a risk stratification of 1 and currently is not at risk for anything. How could Medicare dock you if the patient has no risks and you completed everything else to qualify for the AWV?
2.) The provider takes a social history and discovers the patient is heavy smoker, he advises the patient to quit and gives him options for cessation. However, that is only in the history and not anywhere else in the note. Would that qualify for the risk factors requires in the AWV or does it have to be listed somewhere else in the note as well?
Please answer with links and documentation if available.
Thank you,
Amanda K, CPC, COBGC