How Do I Do the Annual Wellness Visit?
Medicare's AWV begins with a comprehensive Health Risk Assessment
The Centers for Medicare and Medicaid Services (CMS) introduced the Annual Wellness Visit (AWV) benefit in 2011 with the goal of helping “Medicare patients understand the importance of disease prevention, early detection, and lifestyle modifications that support a healthier life.” Though the expansion of preventive services was well intentioned, primary care providers have been slow to embrace, promote and perform the service, as evidenced by less than 3 million (or roughly 6%) eligible Medicare beneficiaries receiving an AWV in 2011.
I frequently hear several reasons cited by fellow practitioners for their reluctance to perform the AWV. Perhaps the most concerning, and the one I will focus on currently, is the lack of understanding of what is required to perform the AWV.
The first concept that MUST be grasped regarding the AWV: it is NOT a traditional comprehensive physical exam. In fact, virtually no exam is required at all (with the exception of a few vital signs and body mass index calculation). While some patients might initially bristle at the idea of seeing a doctor without an exam being performed or chronic conditions being addressed, many patients are appreciative of the opportunity to spend dedicated time with their providers discussing health risks, lifestyle optimization, disease prevention, and age-appropriate screening benefits. Furthermore, on-going individualized health risk assessment (HRA) and formation of a personalized health plan has been identified as an important component in the move towards personalized health care.
Now that we have gotten that out of the way, we can get down to the details.
The cornerstone of the AWV is the HRA Plus process, a patient-centered health risk assessment combined with appropriate screening, referral and follow up to optimally achieve health improvement goals. Substantial evidence supports the efficacy of the HRA Plus process in effecting positive change on health behaviors and biometric measures. In 2011, the Centers for Disease Control and Prevention summarized this evidence en route to providing guidance to CMS and healthcare providers in how best to implement and administer the HRA in its “A Framework for Patient-Centered Health Risk Assessments: Providing Health Promotion and Disease Prevention Services to Medicare Beneficiaries.”
The HRA should collect self-reported patient information and be completed in less than 20 minutes. Careful attention, however, must be paid to the required components, as the 2012 Final Rule clearly states the HRA should contain “at a minimum:”
- Demographics including age, gender, race, ethnicity
- Self-assessment of health status, frailty and physical functioning
- Psychosocial risks (depression, stress, anger, pain, fatigue, social isolation)
- Behavioral risks (including, but not limited to tobacco use, physical activity, nutrition, oral health, alcohol consumption, sexual health, motor vehicle safety, home safety)
- Activities of Daily Living (including, but not limited to dressing, feeding, toileting, grooming, bathing, physical ambulation)
- Instrumental Activities of Daily Living (including, but not limited to shopping, food preparation, using the telephone, housekeeping, laundry, mode of transportation, responsibility for own medications, ability to handle finances)
In addition to administration of the HRA, the AWV must contain the following elements, including personalized prevention plan services (PPPS):
Past medical/family history
- Past medical/surgical history, including allergies, operations and hospital stays
- List of prescribed and over-the-counter medications and supplements
- Medical history of beneficiary’s parents, siblings and children
List of beneficiary’s current providers and suppliers
- To include height, weight, body mass index (or waist circumference), blood pressure
Assessment for cognitive impairment
Review of risk for depression
- Requires use of a standardized screening test
Review of functional ability and safety
- Hearing impairment
- Ability to perform Activities of Daily Living
- Fall risk
- Home safety
Provide patient with written screening schedule for next 5 to 10 years addressing recommendations by USPSTF, Advisory Committee of Immunizations Practice (ACIP) and for age-appropriate preventive services covered by Medicare
Establish a risk of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or underway and a list of treatment options
Provide personalized health advice and/or referrals for health education and preventive counseling services to reduce health risks and promote:
- Self-management and wellness
- Weight loss
- Physical activity
- Tobacco-use cessation
- Fall prevention
Keys to Compliance
Great care must be taken to ensure appropriate documentation when performing the AWV. CMS mandates that ALL required elements of the AWV must be provided and documented to receive payment. With Medicare Recovery Audit Contractor (RAC) activities increasing ($4.2 billion were recovered by RAC programs last year), it is advisable to regularly review and verify documentation compliance.
Though many providers are failing to fully collect and document the necessary elements, I believe this can be remedied with a better understanding of the mandatory components as provided above. Unfortunately, I am also commonly encountering two additional compliance errors.
First, CMS notes they “would not expect that the health professional would provide only general recommendations during the annual wellness visit encounter and then mail a personalized prevention plan that incorporates the HRA to the beneficiary outside of the annual wellness visit encounter.” Therefore, practitioners must ensure they provide specific, personalized recommendations. Counseling such as “exercise more,” “lose weight” or “work on eating a healthy diet” appears unlikely to meet compliance requirements.
Finally, be sure patients “leave the visit with personalized health advice, appropriate referrals, and a written individualized screening schedule, such as a check list.” As noted above, mailing the PPPS after the visit is explicitly cited as unsatisfactory by CMS.
In summary, Medicare’s Annual Wellness Visit aims to prevent and/or slow the progression of chronic conditions through the administration of a patient-centered health risk assessment and personalized prevention plan. Careful attention must be paid to the required elements established by CMS in order to maintain appropriate documentation and guarantee compliance and reimbursement.
With the extent of the above requirements, I suspect you are thinking…“The AWV is just not worth the hassle.”
Rambod Rouhbakhsh, MD is a board certified Family Physician and the Chief Medical Officer at AWVSolution.com where he uses the knowledge and insight he gained as a practicing primary care physician to help design and develop digital solutions to improve access and convenience for patients and providers completing Medicare's Annual Wellness Visit. Please contact Dr. Rouhbakhsh at firstname.lastname@example.org with questions and/or comments.