Annual Wellness Visits (AWV) Decision Tree
This set of questions will assist with review of documentation requirements:
1. Is the provider approved by Medicare (MD, DO, NP, PA, CCNS or Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of medical professionals directly supervised by a physician)?
2. Does all documentation meet signature requirements and include the name, signature and credentials of the person performing the service?
Yes No
3. For G0438 Initial Wellness Visit: Has the beneficiary met Medicare eligibility for 12 months prior?
For G0439 Subsequent Annual Wellness Visit: Is there 12 months since prior AWV performed?
Yes No
4. Is there a Health Risk Assessment present?
Yes No
5. Does the Health risk assessment include the following elements:
- Collects beneficiary self-reported information
- Complete independently by the beneficiary or with assistance
- Considers needs of populations, language proficiency, and health literacy needs.
- Takes less than 20 minutes to complete.
- Addresses the following topics:
- Demographic data, age, gender, race, and ethnicity.
- Self assessment of health status, frailty, and physical functioning.
- Psychosocial risks, depression, stress, anger, loneliness, pain, and fatigue.
- Behavioral risks, tobacco use, physical activity, nutrition, alcohol consumption, sexual health, motor vehicle safety (seat belt use), and home safety.
- Assess ADLs, dressing, feeding, toileting, grooming, physical ambulation (falls), and bathing.
- IADLs, shopping, food preparation, telephone use, housekeeping, laundry, transportation, manage medications, handle finances.
- Review of the individual's functional ability and level of safety:
- Hearing impairment.
- Ability to successfully perform ADL's.
- Fall risk.
- Home safety.
Yes No
6. Are the required initial AWV components discussed or reviewed, for subsequent AWY, in the medical record?
- Establish medical and family history
- Establish list of providers and suppliers
- Use of medications and supplements
- List of providers and suppliers
- Cognitive assessment
- Depression screening
- Functional ability and safety
- Establish screening schedule for beneficiary testing
- Establish list of risk factors and conditions
- Educational and counseling programs for health risks
Yes No
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