A Comprehensive Medicare Annual Wellness Visit Checklist for Providers

A Comprehensive Medicare Annual Wellness Visit Checklist for Providers

The Medicare annual wellness visit (AWV), sometimes referred to as a Medicare annual wellness exam or annual physical exam, is an important part of keeping patients healthy.

Unfortunately, the requirements concerning completing and documenting AWV appointments can be complex, so it is common for providers to miss steps or fail to complete a requirement inadvertently.

If a requirement is missed even once, it can potentially become habitual for you or your staff to neglect that particular step during the Medicare AWV procedure. For instance, you may develop a care plan for the patient but not furnish it to them, or you may create a service schedule that needs personalization to the patient.

Such inadvertent omissions can decrease the worth of the Medicare yearly wellness visit, including the annual physical exam, and potentially result in clawbacks and other penalties. More serious consequences could follow for instances of deliberate and flagrant noncompliance.

The lack of certainty regarding the accurate fulfillment of the Medicare yearly wellness visit, including the annual physical exam, can heighten the challenge for healthcare providers and patients to derive the maximum benefit from these wellness visits.

Checklist For a Compliant Medicare Annual Wellness Visit

Effectively Communicate With Patients

Collaboration between a healthcare provider and their patient is critical for preventive healthcare. To ensure patients are ready to engage in their annual wellness visits, it is vital for healthcare organizations to communicate proactively. 

This includes informing patients of the necessary steps to prepare and the information they should bring to the AWV. Moreover, it is essential to communicate what patients should anticipate during their visit.

A common misconception among individuals is that a Medicare annual wellness visit incorporates a physical examination or other diagnostic procedures. 

Educating patients in advance about the content of an AWV can prevent misunderstandings and disappointment. If you are curious as to why annual physical exams are not covered by Medicare, check out this blog post.

Patients’ Eligibility

If you do not possess the capability of verifying the real-time AWV eligibility of your Medicare patients, you risk missing out on patients or conducting AWVs for those who are ineligible. 

It’s crucial to determine whether your patients have completed their IPPE or “Welcome to Medicare” visit and if they are eligible for a subsequent AWV. 

To maximize the number of AWVs you carry out, you must have a system that can conduct accurate eligibility checks against Medicare’s HETS database in real time. This includes walk-in appointments as well as scheduled appointments.

Identify current medical providers

Numerous patients collaborate with multiple providers to manage their diverse healthcare necessities. 

Constructing a log of each patient’s providers, encompassing medical equipment suppliers and pharmacies is vital to comprehend current and forthcoming medical requirements.

Health Risk Assessment

Medicare mandates the Health Risk Assessment (HRA) as a self-assessment questionnaire for Annual Wellness Visits. It commences with recording standard measurements such as blood pressure and body mass index (BMI). 

After that, patients respond to a range of questions concerning family history, immunizations, medications, existing health concerns, and functional capacity, which can involve screening tests for cognitive impairment, depression, fall risk, and others. The HRA may prompt Advanced Directives discussions. 

Once completed, the HRA enables the provider to have visibility into matters that may not arise during regular appointments. For instance, if a patient is identified as having a high fall risk, the provider may advise on strategies to avoid falls. 

Be aware of vending products with difficult inquiries or poor design features. As the HRA becomes more complicated, elderly seniors may have trouble finishing the questionnaire promptly. To achieve success, large type fonts and accessible design are essential.


Medicare necessitates that your Annual Wellness Visit program produces a custom-made prevention plan, an analysis of risk factors, and a five-year screening plan for each patient. 

Industry standards suggest presenting a simplified version of the care plan for the patient and a more detailed analysis for the provider. The HRA findings can be vast and time-consuming to manually sort through. 

That’s why investing in software that automatically generates these reports for you is advised.

Routine Measurements

Another critical aspect of the annual check-up required by Medicare is the collection of vital signs and other measurements. 

Monitoring data such as weight, blood pressure, and body mass index regularly can assist in identifying potentially worrisome patterns in a patient’s well-being. 

Remote Patient Monitoring Services monitor these vitals for practitioners and care providers remotely and make things easier for them.

Assessment of Mental Health

Mental well-being disorders, like depression, have an adverse impact on an increasing population of individuals. 

Numerous assessment instruments, such as those offered by the American Association for Mental Wellness, can aid healthcare professionals in identifying and effectively managing these conditions.

Cognitive assessment

Certain Medicare beneficiaries may face an increased susceptibility to experiencing reduced cognitive functioning, which can have an adverse impact on their overall well-being and hinder their ability to care for themselves independently. 

Evaluating patients’ cognitive awareness plays a crucial role in promoting their health and safety by promptly identifying any cognitive decline.

Cognitive assessments can be conducted utilizing official instruments, such as those made available by the National Institute of Aging, and/or they can be based on direct observation and feedback from relatives, acquaintances, and caregivers.

Assessment of Daily Functioning and Safety

As individuals grow older, they may experience a decline in their capacity to carry out essential tasks required for daily functioning. 

Consequently, it is vital to conduct screenings to identify issues such as the inability of patients to meet their nutritional or hygiene requirements.

Equally important is the evaluation of whether a patient resides in an environment that does not subject them to unnecessary hazards, such as falls or other accidents, in order to ensure their safety.

Coding and billing correctly

Following a patient’s appointment, the subsequent task on the checklist involves accurately assigning codes and generating invoices for the services provided. 

Healthcare providers must adhere to the regulations governing coding and billing for Medicare annual wellness visits, as any failure to complete the process correctly can lead to claims being rejected or penalties being incurred during audits for non-compliance.

Both outcomes ultimately result in a loss of revenue for the provider.

Integrating RPM Services into the Annual Wellness Exam Medicare Checklist

With technological advancements, remote patient monitoring Services have emerged as a valuable addition to the Annual Wellness Exam Checklist. 

RPM services enable healthcare providers to remotely monitor and gather essential patient data, such as vital signs, symptoms, and medication adherence, to complement the comprehensive assessment conducted during the annual check-up. 

By incorporating Remote Patient Monitoring Services into the checklist, providers can obtain more comprehensive and continuous insights into a patient’s health status, enabling early detection of potential issues and timely intervention. 

This proactive approach of RPM services improves the effectiveness of the annual wellness exam and enhances patient outcomes and engagement in their care.

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