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Checklist: Annual wellness visit (AWV)

This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for AWV. Health care providers retain responsibility to submit complete and accurate documentation.

Check Documentation description
  Documentation is for the correct beneficiary and date of service.
  Documentation is complete, legible, signed and dated by the physician or clinician.
  Documentation that supports the AWV occurred, and the patient has not received an initial preventive physical examination (IPPE) or initial or subsequent AWV within the previous 12 months.
 

Documentation supports the following components of the initial AWV:

  • Health Risk Assessment (HRA) at a minimum the following should be included:
    • Demographic data, self-assessment of health, psychosocial risks and behavioral risks, activities of daily living (ADL) and instrumental activities of daily living (IADL).
  • Medical and family history.
  • List of beneficiary’s current providers and suppliers.
  • Beneficiary’s height, weight, body mass index, blood pressure and any other routine measurements deemed appropriate based on the medical and family history.
  • Assessment of cognitive function.
  • Review of the beneficiary’s potential risk factors for depression (includes any current or past experiences with depression or mood disorders).
  • Review of the beneficiary’s functional ability and level of safety that includes at minimum the following:
  • Ability to successfully perform ADLs and IADLs.
  • Fall risk.
  • Hearing impairment.
  • Home safety.
  • Establishment of an appropriate written screen schedule for the beneficiary for the next 5-10 years.
  • Establish a list of the beneficiary’s risk factors for which primary, secondary or tertiary interventions are recommended.
  • Evidence that personalized health advice, education, preventive counseling, and appropriate referrals were provided to the beneficiary.
  • At beneficiary’s discretion, evidence of any advance care planning services provided / discussed.
  • Review current opioid prescriptions.
  • Screen for potential substance use disorder.
  • Optional social determinants of HRA.
 

Documentation supports the following components of the subsequent AWV:

  • Update HRA at a minimum the following should be included:
    • Demographic data, self-assessment of health, psychosocial risks and behavioral risks, ADLs and IADLs.
  • Update the medical and family history.
  • Update the list of beneficiary’s current providers and suppliers.
  • Beneficiary’s weight (or waist circumference, if appropriate) and blood pressure and any other routine measurements as deemed appropriate based on medical and family history.
  • Assessment of cognitive function.
  • Update of the written screening schedule for the beneficiary.
  • Update the list of the beneficiary’s risk factors for which primary, secondary or tertiary interventions are recommended or underway.
  • Update the PPPS that includes personalized health advice, education, preventive counseling, and appropriate referrals for the beneficiary.
  • At beneficiary’s discretion, evidence of any advance care planning services provided / discussed.
  • Review current opioid prescriptions.
  • Screen for potential substance use disorder.
  • Optional social determinants of HRA.
  Medical necessity supported by the medical record (e.g., office / progress notes, history and physical, laboratory test results, etc.).
  If applicable and required, submitted documentation should include a beneficiary waiver of liability.

 

Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.