Elder Care Interprofessional Provider Sheets

Medicare Annual Wellness Visit

Stephanie Nothelle, MD; Danelle Cayea, MD; Jessica Colburn, MD, Johns Hopkins University School of Medicine

April 2018

TIPS FOR THE MEDICARE ANNUAL WELLNESS VISIT
  • An interprofessional team approach to the AWV may improve workflow. There are several tools available to aid in completing the HRA and screening for various conditions.
  • If a patient has an additional concern unrelated to the AWV, or if a provider does an evaluation for a concern identified during the AWV, a provider may also bill for a new or established office-based visit on the same day.
  • Consider using the AWV as a tool for geriatric assessment tailored to a person's goals and life expectancy.

The Medicare Annual Wellness Visit (AWV) is a preventive health benefit for older adults. All beneficiaries enrolled in Medicare Part B for 12 months are eligible for an initial AWV followed by a subsequent AWV every 12 months. As part of the Patient Protection and Affordable Care Act, the AWV is a co-pay-free visit for patients, and providers are reimbursed at a higher rate for this visit than for traditional office visits.  

Elements of the AWV

To receive Medicare reimbursement for an AWV, several elements must be performed and documented. An initial AWV requires review of a health risk assessment form (HRA). The HRA may be completed by the patient or provider either before or during the visit. Table 1 shows the domains that must be addressed in a HRA. Providers may create their own HRA or use standard forms available for public use on the internet (see references/resource list). A form intended for completion by patients must be written at a 6th grade level, and patients should be able to complete it in 20 minutes or less. The provider must also obtain a patient history, including past medical and surgical history, family history, allergies, and current medications, including supplements. Patients must provide a list of other health care providers, if applicable. 

The initial AWV does not require a physical exam, but does require assessment of height, weight, BMI, and blood pressure. Additionally, the initial AWV requires screening for, and detection of, cognitive impairment, depression, functional ability and safety concerns, including fall risk and home safety, performance of activities of daily living, and hearing impairment. 

Table 1: Health Risk Assessment Requirements 
Demographic data
Age, gender, race, ethnicity
Self-assessment 
Health status, frailty, physical function
Psychosocial risks
Depression, stress, anger, loneliness/isolation, pain, fatigue
Behavioral risks
Smoking, physical activity, nutrition/oral health, alcohol, sexual health, seatbelts, home safety
Activities of Daily Living
Dressing, feeding, toileting, bathing, ambulation
Instrumental Activities of Daily Living
Shopping, food prep, telephone, housekeeping, laundry, transportation, medications, finances

Requirements for subsequent AWVs are similar, including completion and review of a new HRA, assessment of BMI and blood pressure, and screening for cognitive impairment. The other information can simply be updated from prior visits. Both initial and subsequent AWVs require giving patients printed information with updated screening and preventive services schedules, an updated list of disease risk factors and treatments, and personalized health advice, as applicable.

Interprofessional Approaches to the AWV

Traditional primary care clinicians, such as physicians and nurse practitioners, are not the only providers who can complete the AWV. Per the Centers for Medicare and Medicaid Services regulations, the AWV may also be completed by registered dieticians, health educators, or other licensed practitioners, or by a team of medical professionals who are under the supervision of a physician. In light of these regulations, there are a number of published approaches to completing AWVs, including pharmacist-led, nurse-led, shared appointment, and inter-professional team visits. 

For example, in the pharmacist-led model, pharmacists typically have a full-day or half-day clinic session devoted to patients for the AWV. Practices create lists of screening tools and standing orders to be placed based on the health risk assessment and screening findings.

In another example, a nurse-led visit model, the nurse completes the health risk assessment review and screening tests at a visit 4-6 weeks prior to the next physician visit, allowing for the patient to complete the necessary referrals or additional tests in the interim. Shared appointments and inter-professional appointments use the skills of numerous professions to see patients either as a group or individually.  

Billing and Coding

When all required elements of the AWV are fulfilled, a clinician can bill Medicare for the AWV. There are two billing codes for the AWV, one for the initial visit (G0438) and one for all subsequent AWV (G0439). If an additional separately identifiable and medically necessary service unrelated to the AWV is provided in the visit (e.g., evaluation of a new cough), Medicare will also reimburse a clinician for a problem-based office visit (99213, 99214) in addition to the AWV. To do so, a modifier (-25) is used with the appropriate CPT code for the level of service provided. 

Additionally, if advance care planning is discussed during the AWV, the appropriate code (99497 for the first 30 minutes of counseling or 99498 for each additional 30 minutes of time) can be used to bill for this service. A provider must provide a diagnosis code with the advance care planning code, but this can be any diagnosis pertinent to the patient's medical care. To waive the patient's deductible for advance care planning, Medicare requires a modifier (-33,) noting that the counseling was completed on the same day and by the same provider who completed the AWV.  It is billed in the same claim as the AWV.  

Opportunities for Geriatric Assessment

The AWV provides a reimbursable, structured opportunity to perform many of the elements of comprehensive geriatric assessment, including screening for falls, functional and cognitive impairment, and safety risks. Table 2 lists suggested efficient and validated screening tools for these assessments. However, some elements of geriatric assessment may not be relevant to an individual, depending on his or her baseline health function.  

The AWV also provides an opportunity to recommend tests and treatments in the context of a person's estimated life expectancy. For example, an 85-year-old woman with multiple chronic diseases, dementia, and functional limitations may choose to focus on short-term goals, such as symptom control and obtaining necessary support in her current living situation. Her AWV screening schedule should include immunizations, but not cancer screening, and her personalized health advice may focus on completion of advance directives, safety, and geriatric syndromes. 

Conversely, a 74-year-old man with few chronic conditions who gets regular exercise may choose to focus on long-term goals, such as disease and preventive service guidelines, lifestyle changes, and care coordination. His AWV screening schedule may include both recommended immunizations and cancer screening, and his personalized health advice may focus on lifestyle modification. 

Table 2. Efficient and Validated Screening Tools

Cognition

Falls

 

Depression

Single item screen: "Do you think you suffer from depression?" or  PHQ-2
 

Hearing

Single item screen: "Do you have difficulty with your hearing?" or 2-foot whisper test 
 

Polypharmacy

Basic activities of daily living

Instrumental activities of daily living

 

References and Resources