Annual Wellness Visit to Provide Personalized Preventive Plan Benefit
Annual Wellness Visit Benefit Overview
What are the required elements for an AWV service in 2011?
CMS decided to distinguish a first AWV visit service from a subsequent service. Thus, the required elements vary slightly, with the first visit service elements being more extensive. The table below describes the required elements of the first AWV service and the subsequent AWV service.
| Requirements for the First Annual Wellness Visit | Requirements for Subsequent Annual Wellness Visit |
| Establishment of the individual’s medical and family history, which entails, at a minimum, the collection and documentation of: past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments; use or exposure to medications and supplements, including calcium and vitamins; and medical events in the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the individual at increased risk. | An update of the individual’s medical and family history as defined for the first AWV. |
| Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual | An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first annual wellness visit providing personalized prevention plan services |
| Measurement of the individual’s height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine measurements as deemed appropriate, based on the individual’s medical and family history | Measurement of an individual’s weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on the individual’s medical and family history* |
| Detection of any cognitive impairment, defined as an assessment of an individual’s cognitive function by direct observation, with due consideration of information obtained by of way of patient report, concerns raised by family members, friends, caretakers, or other | Detection of any cognitive impairment, defined as an assessment of an individual’s cognitive function by direct observation, with due consideration of information obtained by of way of patient report, concerns raised by family members, friends, caretakers, or other |
| Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional as defined in this section may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations Unique to the first visit |
N/A |
| Review of the individual’s functional ability and level of safety, based on direct observation or the use of appropriate screening questions or a screening questionnaire, which the health professional as defined in this section may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations. Review must include, at a minimum, an assessment of: hearing impairment; ability to successfully perform activities of daily living; fall risk; and home safety. Unique to the first visit |
N/A |
| Establish a written screening schedule, such as a checklist, for the next 5 to 10 years as appropriate, based on recommendations of the USPSTF and the Advisory Committee on Immunization Practices, and the individual’s health status, screening history, and age appropriate preventive services covered by Medicare. | Update to the written screening schedule for the individual that was developed at the first AWV. |
| Establish a list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway, including any mental health conditions or any such risk factors or conditions that have been identified through an initial preventive physical examination and a list of treatment options and their associated risks and benefits. | Update the list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway for the individual that was developed at the first AWV. |
| Furnish personalized health advice and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition. | Furnish personalized health advice and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition. |
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