Essential Documentation Guidelines for Medicare Annual

Essential Documentation for Medicare Annual Wellness Visit

The documentation prerequisites for the yearly Medicare wellness visit (AWV) serve numerous aims. Above all, documenting plays a vital role in amplifying the worth of the Medicare Annual Wellness Visit for patients. 

As pointed out by AARP, the Annual Wellness Exam is purposely devised to encourage the adoption of preventative care, recognize health hazards, and strategize for forthcoming healthcare necessities. 

Moreover, the Medicare Annual Wellness Visit presents a chance for patients to rendezvous with caregivers who can additionally administer or arrange preventative services. 

This blog entry will delve into the significance of documentation for meeting Annual Wellness Visit requirements for caregivers.

The Necessity of Documentation for Annual Wellness Visit Requirements

Ensuring compliance with the documentation prerequisites of the Medicare yearly wellness visit is paramount to securing reimbursement. 

Neglecting to fulfill these requirements heightens the chances of claim denial, leading to delayed payment and escalating costs tied to billing and receiving compensation for the provided service. 

These additional expenses may include staff time and the need to reprint documentation.

According to a recent study, a significant portion, approximately 85%, of Medicare annual wellness visits might not meet the standards outlined by CMS.

For a seamless Medicare annual wellness exam experience and accurate reimbursement, let’s review the documentation criteria for initial and subsequent AWVs.

Key Documentation Requirements for the Initial Medicare Annual Wellness Visit

Outlined below are the necessary documentation for initial Medicare Annual Wellness Visits Requirements:

Health Risk Assessment

The health risk assessment (HRA) demands completion either by a beneficiary or healthcare provider before or during the encounter of the Medicare annual checkup. 

At the very least, the HRA should encompass demographic data, self-evaluation of health status, psychosocial hazards, behavioral hazards, activities concerning daily living (ADLs) like dressing, bathing, and walking, as well as instrumental ADLs (IADLs) like shopping, housekeeping, medication management, and financial handling.\

Existing Healthcare Providers and Suppliers

Ensure the comprehensive list encompasses all existing healthcare providers and suppliers consistently delivering care and services to the beneficiary. 

This inclusive roster should encompass primary care physicians, specialized physicians, chiropractors, acupuncturists, pharmacies, herbalists, and therapists.

Medical & Family History 

When documenting a beneficiary’s medical and familial chronicle, it is imperative to gather intricate particulars about the medical occurrences of the patient’s progenitors, siblings, and offspring. 

This includes scrutinizing hereditary or high-risk ailments, past medical and surgical chronicles, and the usage of medications encompassing prescriptions, over-the-counter treatments, dietary supplements, and vitamins. 

In light of the ongoing opioid predicament, healthcare providers are strongly advised to engage in discussions, perform assessments, and diligently record any employment of opioids.

Cognitive Functions 

Thoroughly assessing a patient’s cognitive function and potential for conditions like Alzheimer’s and dementia requires healthcare providers to conduct careful direct observations. 

They should gather information not only from the patient but also from concerned individuals, such as family, friends, and caregivers who have regular interactions with the patient. 

Proper documentation of these findings is essential for a comprehensive wellness visit.

Standard Measurements

To ensure a comprehensive evaluation, capturing fundamental, routine measurements encompassing height, weight, body mass index (BMI) or waist circumference, blood pressure, and any additional pertinent measurements based on the previously mentioned medical and familial background is imperative. 

These measurements are essential for a thorough assessment during the wellness visit.

Determining Factors for Depression Vulnerability

Utilizing an established depression screening assessment, such as those endorsed by the American Psychological Association, meticulously evaluates a beneficiary’s potential vulnerability to depression. 

Thoroughly explore their present or past encounters with depressive episodes or other mood-related disorders.

Written Screening Schedule

This aspect often becomes a stumbling block for healthcare providers when meeting the documentation requirements. 

Providers are expected to draft a written plan for preventive screenings and services for the beneficiary’s upcoming 5-10 years, which forms an essential component of the personalized prevention plan of service (PPPS). 

Embedded within the regulations is the anticipation that patients will be “provided” with a personalized prevention plan and counsel. 

Although the term “provided” lacks a specific definition, it has been construed to encompass either physically handing a copy of the PPPS to the patient upon completing the AWV or placing a copy in the patient’s active health portal account.

Functional ability and safety

By directly observing the beneficiary and possibly employing inquiries from screening questionnaires, evaluate the functional capacity and safety of the patient. 

This assessment should encompass the individual’s proficiency in carrying out activities of daily living (ADLs), susceptibility to falls, hearing impairments, and the overall safety of their living environment.

Factors and Conditions Associated with Risk

Generate a comprehensive catalog of risk factors and conditions necessitating primary, secondary, and/or tertiary interventions. 

This encompasses diverse facets such as mental health ailments (including depression), substance use disorders, cognitive impairments, risk factors identified through the initial preventive physical examination (also referred to as IPPE or “Welcome to Medicare” preventive visit), and the available treatment options along with their associated advantages and disadvantages.

Guidance on Health and Referrals

Healthcare providers are urged to document and disseminate personalized health counsel to beneficiaries meticulously. 

This encompasses recommendations for engaging in health education, seeking preventive counseling services, and participating in programs tailored to lifestyle interventions fostering wellness in various domains, such as shedding excess weight, augmenting physical activity levels, quitting smoking, averting falls, and enhancing nutritional habits.

Upon request: Provision of Advance Care Planning Services (ACP)

If a beneficiary expresses comfort, healthcare providers are encouraged to engage in a detailed discussion regarding advance care planning (ACP) services and accurately document the topics covered. 

These discussions should encompass vital aspects such as forthcoming care decisions, strategies to communicate care preferences to others effectively, caregiver identification, and a comprehensive explanation of advance directives, which may entail completing pertinent forms.

Requisite Documentation for Subsequent Medicare Annual Wellness Visits

Following is the Mandatory Documentation for Subsequent Medicare Annual Wellness Visit: 

  • Revise and Enhance the Health Risk Assessment (HRA)
  • Update and Amend the Beneficiary’s Medical and Ancestral BackgroundRefresh the Roster of Current Healthcare Providers and Suppliers
  • Document Essential, Routine Measurements to Keep Pace
  • Evaluate Cognitive Function, Unraveling the Mind’s Mysteries
  • Delve into Depression and Unearth Risk Factors Through Conversation
  • Refine and Revisit the Written Screening Schedule
  • Stay Abreast of Ongoing Risk Factors and Evolving Conditions Necessitating Interventions
  • Evolve the Prevention Plan of Service, Dispensing Personalized Health Wisdom and Navigating Referrals to Health Education and Preventive Counseling Services
  • Revisit and Reconsider Advance Care Planning Services, Adapting to Individual Preferences

Remote Patient Monitoring Services & Documentation

Documentation plays a vital role in capturing the utilization of RPM services during the Medicare AWV. It is important to ensure accurate and comprehensive documentation to support the integration of Remote Patient Monitoring Services into the AWV process. 

Key elements to consider when documenting RPM services include obtaining patient consent for remote monitoring, detailing the setup process of monitoring devices, documenting the frequency and duration of monitoring sessions, and capturing any communication or follow-up related to the RPM data analysis and care plan adjustments.

Furthermore, accurate billing and coding for Remote Patient Monitoring services are essential to ensure proper reimbursement for the time and effort invested in remote patient monitoring. 

Familiarize yourself with the specific billing requirements and codes for RPM services, such as CPT codes 99453, 99454, 99457, and 99458. Proper documentation and coding will facilitate appropriate reimbursement and ensure compliance with Medicare guidelines.


Proper documentation is crucial for the success of the Medicare Annual Wellness Visit (AWV) and the delivery of comprehensive healthcare to Medicare beneficiaries. 

The documentation requirements serve multiple purposes, including maximizing the value of the AWV for patients and ensuring compliance for reimbursement. 

To ensure thorough documentation, healthcare providers can utilize an annual wellness exam checklist, which acts as a comprehensive guide to capturing all the necessary information during the visit. 

By adhering to the checklist and accurately documenting each component, healthcare providers can streamline the billing and reimbursement process, reducing the chances of claim denials and delayed payments. 

Accurate documentation not only supports the integration of preventative care and identifies potential health hazards but also helps in planning for future healthcare needs based on the patient’s medical history and risk factors.

Schedule A Live Demo
Join us for a tour of the 360healthtek RPM devices Thursday at 10am Pacific, followed by Q&A. We'll cover how RPM data impacts clinical decision making, applicable CPT codes, effects on patient engagement, and much more.