November 6, 2024
Daniel Tashnek, JD
Introduction
Preventive medicine has the potential to save lives. According to the Centers for Disease Control and Prevention, if everyone in the United States received recommended clinical preventive care, more than 100,000 lives could be saved each year.
Though it’s widely recognized that preventive care contributes positively to overall wellness, many challenges exist when it comes to implementing a Medicare preventive screening program in a traditional medical practice. The intention of Medicare in providing the annual wellness visit is commendable; however, the confusion surrounding what this visit is — and what it is not — complicates matters.
In some cases, misinformation and complex requirements lead to patients failing to take advantage of the covered service, thus missing out on the health benefits while practices consequently forfeit revenue opportunities. In other instances, medical professionals may be reluctant to conduct the Medicare annual wellness visit, deeming the potential hassles and convoluted billing process not worth their effort. On top of these, you can add ever-evolving guidelines and coding requirements. In either scenario, the result is the same: missed opportunities for enhanced patient care and revenue that is left on the table.
Even if you are currently performing Medicare annual wellness visits, your healthcare practice may be using unnecessary, inefficient resources to complete the reporting and billing process for these visits or even missing out on revenue for services performed altogether. In fact, a medical practice can be reimbursed initially, but later be forced to return the funds if they are found during an audit to be non-compliant.
With proper tools and proactive communication, the process doesn’t need to be daunting. This guide outlines practical approaches for educating patients and establishing a standardized approach to the Medicare annual wellness visit that is scalable and easy to implement with staff members. In this guide, you'll also find that we’ve uncovered ways to simplify the following key requirements:
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Ensuring eligibility requirements
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Executing each component of a visit, including health risk assessments (HRAs)
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Maintaining compliance through proper documentation
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Staying current on guidelines from the Centers for Medicare & Medicaid Services (CMS)
Many healthcare practices find that technological resources are essential to make delivering the annual wellness visit worthwhile. Technology can ease the human burden by automating steps toward better patient communication and meeting reporting and billing guidelines. When practices take a systematic approach to the Medicare annual wellness visit, everyone wins.
Chapter 1: What Does the Medicare Annual Wellness Visit Include?
One of the greatest challenges medical practices face today is clearing up the confusion about the Medicare Annual Wellness Visit — more specifically, what it is and what it is not. Understandably, Medicare patients often erroneously assume that this is the equivalent of an annual physical exam. However, that is not the case. The headache that medical practices often face is the aftermath of the confusion, which can include everything from angry patients to coding errors that jeopardize reimbursement. The end result can be apathy and missed visits.
For health care providers to cut through the confusion, it’s essential to have a clear grasp of the differences in these two types of services and review what Medicare covers.
Medicare Annual Wellness Visit vs. Annual Physical Exam
CMS notes that a "routine physical examination" is not covered by Medicare. As such, Medicare patients will be expected to cover the entire cost of the service (unless supplementary insurance provides coverage).
Unlike a yearly physical exam that can take about 30 minutes during which a physician measures all vital signs, thoroughly examines a patient from head to toe, and submits orders, like urine samples or blood tests, the Medicare Annual Wellness Visit does not provide such a thorough exam. Rather, it focuses on prevention planning and reviewing the medical history.
Instead of being guided by hands-on measurements, the Medicare annual wellness visit is driven by the health risk assessment. The HRA is a questionnaire and screening tool that provides an assessment about health status and provides feedback about actions that can be taken to reduce risks and promote health. Patient communication when performing the health risk assessment is key.
The provider works with patients to develop a personalized prevention plan, which requires the following:
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medical and family history;
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a list of current providers and prescriptions;
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gathering of routine measurements;
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treatment options for risk factors; and
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development of a screening schedule.
In addition, providers may assess for cognitive impairment or look for signs of Alzheimer's disease or dementia. Medicare patients pay nothing for the annual wellness visit; however, they must be eligible for the service. Medicare.gov notes that beneficiaries with Medicare Part B for longer than a year are eligible once every 12 months.
It should be noted that during the first 12 months, a patient who is newly covered by Medicare Part B is also eligible for an initial preventive physical examination, or IPPE, to review medical and social history as well as health screenings that can include flu shots, vision tests, routine measurements, and referrals for other care. This visit, which is commonly referred to as a "Welcome to Medicare" visit, is covered only once and only in the first 12 months of coverage.
Checklist Items for the Medicare Annual Wellness Visit
To adequately educate their patients about coverage and efficiently execute an annual wellness visit, providers need a clear outline of what should happen before, during, and after each visit.
Before the visit, practices should take the following steps:
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Verify eligibility
Medicare will only reimburse if a patient has been enrolled for more than 12 months and has not received an annual wellness visit or a Welcome to Medicare preventive visit in the preceding 12 months.
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Communicate requirements and expectations
Proactively communicating with patients about what to expect is a best practice. Make certain they know which documents to bring to an appointment and understand how the annual wellness visit is different from a yearly physical.
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Have patients complete an HRA
The health risk assessment is a questionnaire completed by patients that provides information required to reconcile existing medication and health records with the patient’s responses.
During the visit, a patient should be educated to expect the following:
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Routine measurements
These include measurements such as weight, blood pressure, and body mass index.
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Cognitive assessment
For patients who are aging and at increased risk of cognitive decline, these assessments may include tools such as those provided by the National Institute of Aging or they may be based on direct observation and input from family members, friends, and caregivers.
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Mental health assessment
Screening tools are available to help patients with depression, like those provided by the Substance Abuse and Mental Health Services Administration.
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Everyday living and safety assessment
As patients age, it’s critical to assess how well they perform the tasks of daily living and for providers to guide them through dealing with challenges in their environment.
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Documentation of risk factors
Providers should compile and document a list of potential risks that may negatively impact a patient now or in the future. This list should include the risks themselves and the advantages and disadvantages of any treatment options.
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Discuss advanced care planning
For patients interested in addressing the care they would want to receive if facing a medical crisis, another step is a discussion of advanced care planning.
After the visit, providers should complete the following:
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Personalized plan of care
Provide patients with a personalized patient plan of care that considers all of the information gathered from assessments. This plan should accomplish three things: 1) provide specific medical advice for identified risks; 2) provide an actionable screening schedule for a 5- to 10-year period; and 3) provide patients with a physical copy of all items covered.
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Check coding and billing for completion and accuracy
Ensure that coding and billing are completed correctly to avoid reimbursement disruptions. (Note: Read Chapter 4 for a detailed look at this topic.)
Who Can Perform a Medicare Annual Wellness Visit?
Crucial for practices to understand is that Medicare does not require annual wellness visits be performed only by a patient’s primary care physician, despite some definitions indicating such. According to an independent reference tool Medicare Interactive: “The annual wellness visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan.”
Medical practices should understand the distinction between “performing” or “providing” the service. "Perform" in this context means the ability to complete the AWV with the patient under the "general supervision" of a provider, with general supervision meaning the service is furnished under the physician's overall direction and control but the physician's presence is not required. "Provide" in this context means an individual is the actual billing provider of the Medicare annual wellness visit, i.e., holder of the National Provider Identifier (NPI) in the Medicare claim.
In addition to MDs — which includes cardiologists and other specialists — and DOs, other healthcare professionals who can provide the Medicare annual wellness visit are as follows:
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Physician assistants
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Nurse practitioners or clinical nurse specialists
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Urgent care providers
It’s also worth noting that an AWV can sometimes be provided via telehealth.
Now let’s examine who can perform the AWV. Since the AWV can be conducted by clinical staff under the supervision of a provider, the broader answer to "who can perform the Medicare annual wellness visit" is anyone a provider has oversight of and trusts. If this categorization sounds rather broad, that's because it is — and it encompasses more than most understand. For instance, while the vast majority of practices use medical assistants or other "clinical staff,” under supervision, practices can even use contracted staff or engage in collaborative partnerships like those with pharmacists.
With such a broad definition, time-strapped providers can optimize efficiency using their clinical staff to offer more services. Perhaps no healthcare professional has more capacity to play an increased role as the pharmacist. In fact, a new healthcare delivery model is emerging, and practice administrators and providers are taking note of the value of incorporating a pharmacist into their practice care team. With the addition of a pharmacist, a practice can enhance the delivery of positive patient outcomes and improve medication and treatment adherence rates, all while reducing the overall cost of delivering good patient care and possibly growing volume in the process.
Together, the PCP and pharmacist team can encourage better patient adherence to treatment regimens, thus improving CMS measure scores that can preserve or boost reimbursement. Some practices even choose to integrate pharmacists into their practice to accomplish these goals. Notably, pharmacist integration is not likely to be as simple as "plug and play." Rather, as a Pharmacy Practice article notes, fully realizing the value of adding pharmacists to the team to conduct annual wellness visits will require an ongoing emphasis on interprofessional training.
One way to achieve a pharmacist-PCP partnership could be to hire a pharmacist. Another popular way to integrate a pharmacist into the care team is through a collaborative practice agreement (CPA) that would allow the pharmacist to come into a practice on a contract basis to perform annual wellness visits.
CMS takes no position on the particular tasks that should and should not be performed by specific members of such a team. Rather, CMS states that it believes it is better for the supervising physician to assign tasks to appropriate team members.
Chapter 2: Benefits of the Medicare Annual Wellness Visit for Patients and Practices
Many providers question whether providing the Medicare annual wellness visit is worth their time and resources. However the evidence shows that it can clearly be a net positive, if approached correctly. To be sure, the large Medicare-eligible population represents a great portion of the market, which can generate recurring income for a practice.
With a streamlined and clear plan, the Medicare annual wellness visit delivers the following advantages to providers:
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Improved patient education — Setting clear expectations with patients prior to visits can build trust and facilitate open communication, leading to more optimal care. By changing workflows to incorporate more proactive communication, providers also tackle time constraints for in-office time when questions are answered preemptively. More efficiency ultimately equals more revenue.
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More comprehensive care delivered in an efficient timeframe — With the use of specialized annual wellness visit or preventive care software, and by simplifying the process with patient forms and workflow, providers can cover more ground in less time.
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Opportunities to provide advanced care planning services — While the ACP discussion is considered voluntary and can be completed at any time, if the service is performed during the patient’s annual wellness, there is no cost to the patient. In addition, and unlike the AWV, there is no limit other than necessity to the number of times ACP visits can be billed per patient per year. This is significant, especially when you consider that according to a Medscape report, less than 3% of qualifying medical providers are conducting and billing for ACP services. Advance communication goes a long way toward preparing a patient to discuss sensitive topics.
What are the benefits of the Medicare annual wellness visit to patients? They include the following:
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Empowering patients with resources — It is said that "information is power." When completed successfully, the knowledge provided to patients during the annual wellness visit should enable them to take an active role in their health and treatment plan.
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Providing patients with prevention services — The visit is a chance for providers to recommend further treatments that can aid in proactive healthcare planning.
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Establishing confidence in their providers — With the level of communication that the Medicare annual wellness visit necessitates, patients work closely with their healthcare providers, often achieving better rates of compliance and treatment adherence because they have a clearer understanding of health goals.
Medical software plays an essential role in the logistics of providing and documenting services by ensuring each visit is complete and eliminating human error in meeting requirements.
Chapter 3: Implementing the Medicare Annual Wellness Visit Efficiently and Overcoming Challenges
Now that you have a general understanding of the scope of the challenges associated with conducting the annual wellness visit, it’s easier to see why establishing a template for providing the Medicare AWV is of great value for addressing the time constraints of a busy practice and staff. A major component of any template focuses on delivering patient education in a standardized and consistent manner.
Education
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Review important distinctions with your patient —A discussion should cover matters such as the differences between an annual wellness exam vs. annual physical exam vs. IPPE (if applicable), what the patient's insurance will and will not cover, and how much money the patient will need to pay out of pocket for the wellness visit. When these issues are addressed in advance, it reduces the likelihood of a negative patient experience due to a surprise medical bill. Why does this matter so much? When patients are dissatisfied, collecting their portion of the bill often becomes more difficult, and they may decide to vent their frustrations to staff or online, which can negatively impact a provider's reputation or waste valuable time.
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Be transparent about additional services — If you determine that it is imperative to provide treatments or additional preventive services not covered under the Medicare annual wellness visit, it’s a best practice to explain to patients why you recommend these services and what they are likely to cost patients before proceeding with the treatment or recommendation.
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Ensure adequate training of all staff members involved — Make sure staff grasps the differences between a Medicare annual wellness visit and an annual physical exam and why those differences matter from a coding, billing, and reimbursement perspective.
A customizable, holistic wellness platform can aid staff and patients with education by improving eligibility verification, patient outreach and intake, billing and coding, documentation requirements, and compliance.
Patient Preparedness
A worthwhile goal for practices is to expedite completion of the Medicare annual wellness visit while still meeting patient needs and requirements. We have outlined 5 steps to take to better prepare patients for the AWV:
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Provide patients with a summary of annual wellness visit services —You don’t want to overwhelm patients with too much information, so keep the summary concise. It should feature the main actions you will take, descriptions of services, a summary of what to expect, and medical definitions, when applicable.
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Explain that additional services may be warranted — As the saying goes, “an ounce of prevention is worth a pound of cure.” Therefore, prepare patients for the possibility that you will recommend services that require them to pay out of pocket to cover some or all of the costs.
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Differentiate between annual wellness visit and annual physical exam — This fact cannot be overstated; it’s about setting the right expectations. An unhappy patient who is surprised or disappointed when the Medicare annual wellness visit does not include services they assumed were included can be a drain on efficiency.
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Help patients help you save time — Here’s how: Ask them to bring a wide array of information to the visit, including medical records, immunizations, detailed family health histories, complete list of medications, complete list of care providers and suppliers, list of durable medical equipment, the completed health risk assessment (HRA), and a list of their questions or concerns. This not only aids in the quality of care but can also promote accuracy of documentation of services.
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Share annual wellness visit resources — CMS provides an excellent resource library that can help patients find the information they need and, therefore, cut back on calls to your office. Consider email or texting links prior to their appointment.
Streamlining Your Process for Implementing the AWV
Medical providers who have increased the number of Medicare annual wellness visits performed and done so efficiently have at least one thing in common: They are strategic about their approach. The best way to accomplish this is to establish a systematic and scalable visit template covering everything from start to finish. A template eliminates planning hours and also prompts staff to proactively document and evaluate patient health risks. By simplifying the process, more patients can be served in the same amount of time, allowing for more revenue opportunities.
Important components that all annual wellness visit templates must include to meet Medicare requirements are as follows:
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Eligibility
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Pre-AWV preparation
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Exam checklist items
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Subsequent AWV questionnaire (performed one year after the initial AWV)
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Billing records
It’s key to integrate any template into the clinic’s existing patient management system.
In addition to determining which staff members will be responsible for providing different aspects of the service, you must also plan for how the Medicare annual wellness visit will integrate into established processes.
Improve your Annual Wellness Visit process
Check out our AWV Toolkit and download five helpful resources to get started.
Chapter 4: Addressing Reimbursement, Financial, and Compliance Concerns
A big piece of the puzzle for making preventive services viable requires medical practices to complete coding and billing of the Medicare annual wellness visit accurately. Doing so helps ensure practices earn full reimbursement and can protect practices from penalties incurred from failed coding audits.
Though a comprehensive review of all Medicare codes associated with the Medicare annual wellness visit would be overly burdensome, it is beneficial to review some of the most common codes used: G0402, G0438, and G0439.
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G0402 — This is the code for a one-time IPPE (or Welcome to Medicare visit) that must take place during the first 12 months of Medicare enrollment. Why is this tricky? After a patient has been enrolled for more than 12 months, the G0402 code will be rejected regardless of whether the IPPE visit previously took place or not.
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G0438 — If a patient completed an IPPE, the patient is eligible for the initial AWV on the first day of the same calendar month the following year. Use this code exclusively for the initial AWV.
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G0439 — This is used to code all subsequent annual wellness visits that occur after the initial annual wellness visit (coded G0438).
Why is correct coding so important? In addition to ensuring accuracy to avoid rejected reimbursement, another reason is potential missed revenue. For example, the G0438 code is reimbursed at a rate that is nearly 50% higher than G0439. If a medical practice regularly fails to use the G0438 code for the initial Medicare annual wellness visit and uses G0439 instead, it could mean a significant loss of revenue.
In addition to these primary visit codes, a select list of other codes may be billed for services performed during a Welcome to Medicare or annual wellness visit. Many of these codes have guidelines that require them only to be used with specific services after meeting certain criteria.
Staying Current
One of the biggest hurdles for medical office staff is staying up to date on changing guidelines and eligibility requirements that affect coding and subsequent reimbursement. Practices can avoid risking an audit by staying current on coding requirements. For example, codes often get replaced, such as G0436 (smoking cessation counseling for 3 to 10 minutes), which was replaced by 99406 (smoking and tobacco use cessation counseling). Such a revision is fairly common.
When your focus is on patient care, who has time to monitor fluctuating regulations? Fortunately, we’ve done some of that work for you.
Opioid Assessment
A significant development from the past few years that affects providers performing the initial preventive physical examination and annual wellness visits is Medicare emphasizing that the review of opioid use and opioid use disorders (OUD) should be considered routine components of the IPPE and AWV. As we noted, "By including an opioid risk assessment as a standard component of the IPPE and AWV, CMS is trying to play a role in helping combat, spread awareness of, and provide education on the ongoing opioid crisis." You can learn more about the review of opioid use during the initial preventive physical examination and annual wellness visit in this MLN Matters special edition article.
The Increasing Role of Telehealth Services
Telehealth, telemedicine, and related terms generally refer to the exchange of medical information from one site to another through electronic communication to improve a patient’s health.
While the ongoing and evolving response to the novel coronavirus (COVID-19) has thrust telehealth service into the spotlight, the reality is that telehealth delivery models were already on the rise. For 2020, CMS added the following codes to the list of telehealth services: HCPCS codes G2086, G2087, G2088, which describe a bundled episode of care for treatment of opioid use disorders.
As of March 6, 2020, and for the duration of the COVID-19 public health emergency, CMS stated that it will pay for professional Medicare telehealth services furnished to beneficiaries in all areas of the country in all settings. These visits will be considered the same as in-person visits and paid at the same rate as regular, in-person visits. Services covered include the Medicare annual wellness visit and Medicare preventive services. These temporary changes are meant to allow providers the opportunity to continue to care for their patients from afar while the threat of coronavirus remains high. CMS continues to update a blanket list of waivers for the duration of the emergency. Check its website for ongoing updates as they become available.
Since annual wellness visits may be conducted via audio-only telehealth (i.e., over the telephone) for the duration of the waiver, there are some essential considerations to keep in mind:
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All the normal service and documentation requirements for the in-person AWV remain the same for a telehealth AWV. Billing and coding use the same CPT and ICD codes, but you should add modifier -GT to signify it was performed via telehealth. During the crisis, Medicare is reimbursing telehealth AWVs at the same rate as it would if the visit were completed in-person.
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The vast majority of the annual wellness visit requirements can be easily performed via telehealth without adaptation, with one exception: collecting patient vital measurements. CMS has not specifically stated how best to collect measurements in this situation, but it is important that you have patients self-measure their vitals to the best of their ability.
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Document each of these measurements as “patient reported.” If patients are unable to provide any of the measurements, document them as “unable to obtain from patient” as opposed to leaving them blank.
To maximize the benefit of the AWV using telehealth services, providers can also add the following preventive services:
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Advance care planning (99497, 99498)
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Alcohol screening/counseling (G0443, G0396)
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Depression screening (G0444)
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Cardio risk counseling (G0446)
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Medical nutrition therapy
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Diabetes self-management training
View a full list of the services Medicare is allowing via telephone on the CMS website.
Chapter 5: Evaluating and Optimizing the Process
Providers who wish to expand or streamline Medicare annual wellness visit services must be careful. From the first contract to the last bill, one documentation error can jeopardize reimbursement. In addition, the time that it takes to wade through requirements can distract from patient care. The good news is that it doesn’t have to. Establishing a systematic approach to the Medicare annual wellness visit is the best course for delivering comprehensive preventive patient services. There are many factors to consider for AWV compliance, in addition to the following questions, here are some key takeaways from a recent AAFP survey.
When working to improve your process, it’s important to consider the following questions:
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Can your electronic system automatically identify eligible patients and their annual wellness visit history?
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Do you have a system in place that generates this list once a month/quarter?
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Will your system identify patients who are soon to be eligible for an AWV?
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Is there an electronic/automated option in your system for reaching out to patients to remind them that it's time to schedule their AWV?
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Will your system ensure maximum compliance with HIPAA?
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Does your AWV template allow you to efficiently increase the reimbursement your practice is eligible for?
The best way to implement a template for the Medicare annual wellness visit across your clinic is through a single preventive care platform that compliments your existing system for maintaining electronic health records.
With patient care to focus on, many practices find that using an end-to-end software platform can help them manage the avalanche of documentation and coding requirements, eligibility requirements, patient communication forms, outreach efforts, and billing. In return, these practices can expect to significantly reduce the time spent per preventive visit per patient, expand revenue, and capture increased revenue. Having a "single source of truth" for staff who are taxed with other responsibilities also helps to ensure accurate billing and consistent care practices.
But above all else, the solution needs to help patients achieve better overall health. If you are looking for an all-in-one solution that allows you to automate your practice’s workflow and significantly increase revenue without requiring additional work, Prevounce may be a good fit for your organization or office. If you’d like to learn more about our platform, schedule a demo with us here.
Download the Annual Wellness Visit Toolkit.
Get the tools you need to make sure it's done right.
To get started on improving your current process or implementing a new one, check out our AWV Toolkit, which includes:
- Booklet: ABCs of the AWV
- Postcard: Reminder for the AWV
- Patient Handout: Explanation of the AWV
- Whitepaper: Prevounce Techniques to Achieve Better AWV Participation Rates
- AWV Checklist
Looking to optimize your Medicare annual wellness visit process?
Not only can Prevounce streamline your AWV, but we can also provide a practice-specific, single-source wellness solution that makes preventive and chronic care management easier to prep for, perform, document, and bill.
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