Medicare Annual Wellness Visit (AWV)Streamline Workflow to Perform a Thorough AWV

1. Describe the Centers for Medicare and Medicaid Services requirements for the Medicare Annual Wellness Visit

2. Assist with setting appropriate patient expectations for the Annual Wellness Visit

3. Provide an example of an efficient Annual Wellness Visit workflow for care team members

Since the passage of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) has made a concerted effort to reform the payment schedule to promote preventive care and improve care coordination and chronic disease management for patients under Medicare. The Annual Medicare Wellness Visit (AWV) was the first of these changes to be introduced, followed by codes to reimburse physicians for transitional care management, chronic care management, advance care planning, and cognitive assessment. These reforms support the evolution of advanced primary care practices consistent with the idea of the patient-centered medical home. However, certain changes in day-to-day operations are required for primary care physicians to adapt to these changes.

Quiz Ref IDThe AWV is a type of office visit in primary care that involves preventive care, advanced care planning, and depression and dementia screening.¹ It is an opportunity for physicians to update important information in a patient's chart such as the problem list or medication list, as well as to create and maintain a personalized screening and prevention plan. The AWV also identifies factors that, if not attended to, can negatively impact an older individual's health status (eg, mental health concerns, cognitive impairments). Accomplishing these tasks often involves in-depth conversations and non-face-to- face work, which is important and different from the focus of more traditional medical visits. The important tasks embodied within the AWV simply cannot be addressed adequately in a regular problem-based office visit. Incorporating a separate AWV not only removes the time constraint in accomplishing this critical work, but also provides a way for physicians to be reimbursed for it. As a result, these tasks are no longer viewed as an extraneous burden to tack onto a regular office visit, but appropriately as meaningful work. Ultimately, this feeling of accomplishing meaningful work that directly improves patient care is one of the drivers of joy in practice.

1. Understand the Annual Wellness Visit (AWV)

2. Communicate with Patients to Set Expectations for the Annual Wellness Visit (AWV)

3. Map Out an Annual Wellness Visit (AWV) Workflow

CMS covers two types of annual wellness visits, an initial visit (G0438) and a subsequent visit (G0439).¹ The initial visit is the first time a patient under Medicare receives an AWV, and subsequent visits include all subsequent AWVs. These are both different from the Initial Preventive Physical Examination (IPPE), which is a one-time visit for a patient within 12 months of enrollment in Medicare Part B. AWVs are for patients no longer within 12 months of enrollment and are covered once every 12 months. Detailed information about each of these visits can be found on the CMS website; bullet points of main topics are listed below. Answers to frequently asked questions (FAQs) about the AWV from the American Academy of Family Physicians (AAFP) can be found here.

The components of an initial AWV:

• Perform a Health Risk Assessment (HRA).

• Establish medical and family history

• Establish a list of current health care providers and suppliers

• Measure vitals

• Screen for cognitive impairment

• Review potential risk factors for depression

• Review functional ability and level of safety

• Establish an appropriate written screening schedule for the next 5 to 10 years

• Furnish personalized health advice and appropriate referrals to health education or preventive counseling services or programs

• Establish a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or underway

• Discuss optional advance care planning services

A subsequent AWV contains essentially all the same components as an initial AWV, except the goal is to review and update each of the components rather than establish them de novo.

Many physicians choose not to perform an AWV because they perceive it to be too onerous. Adoption and routine use of the AWV across the country remains low to modest at best.¹Quiz Ref IDHowever, most of the components of the AWV can (and should) be performed by the non-physician care team, including medical assistants (MAs). Their job should be to collect the data; your job is to synthesize the findings and provide recommendations. In short, you don't have to do it all.

Medicare covers the AWV if it is furnished by a:

• Physician (Doctor of Medicine or Osteopathic Medicine)

• Physician assistant

• Nurse practitioner

• Certified clinical nurse specialist

• Medical professional (eg, health educator, registered dietitian, nutrition professional, or other licensed practitioner) or team of medical professionals (which can include medical assistants) working under the direct supervision of a physician. Direct supervision is defined as being physically present in the office suite to render assistance, if necessary.

Nonphysician staff can collect and record data from the HRA, administer questionnaires (such as the PHQ9), pull up records of prior screening activities (such as when the patient last had colon cancer screening and what kind) and conduct a wide range of other activities. Staff cannot interpret the results, create the care plan, order tests independently, or bill for the service without the participation of the physician or qualified nonphysician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist).

The AWV is well-reimbursed by Medicare, as illustrated in the table below.

Work Relative Value Units (RVUs) represent RVUs for activities performed personally by the physician. Work RVUs are the basis for many productivity-based physician contracts. Total RVU represents the sum of work RVUs plus RVUs for practice expense (eg, non-physician care team, equipment, and supplies) and malpractice expense. When the physician practice bears the cost of work RVUs, practice expense, and malpractice expense, total RVU is the basis of payment. This is true for the nonfacility setting, typically a private practice. Many hospital clinics are also paid this way.

Sometimes a hospital claims facility status. In that case, the hospital is paid for practice expense through the Hospital Outpatient Prospective Payment System. Payment for practice expense through the Physician Fee Schedule is therefore reduced, so that the total facility RVU will be less than the total nonfacility RVU. Work RVU is the same whether claiming facility or nonfacility status.

The AWV is not the same as an annual physical (CPT codes: 99381-99397), and does not include a physical exam. Unlike with commercial insurers, there is no such thing as an “annual head-to-toe physical” when it comes to Medicare. What Medicare does cover are 1) problem-based visits that may involve some directed physical exam and diagnostic work up (an Evaluation and Management, or E&M, visit), and 2) the AWV. There are exceptions, however, as some Medicare Advantage plans provided via commercial insurers do cover an annual physical exam. Alternatively, some practices do perform an “annual exam” and charge patients directly (this should not be billed to Medicare).

It is essential to explain this to patients prior to their visit either with a phone call, handout, or FAQ letter.

The AWV can be performed on the same day as a routine E&M visit (to address problem-based concerns), or it can be separated into its own visit. There are pros and cons for each strategy, as described in the table below.

After you decide whether to use a combined or separate visit approach for the AWV and problem-based visits, your office workflow can be established. Refer to the sample process map of the AWV workflow below for guidance on how to map out each step.

CMS now recognizes the important work done by primary care physicians that is different from the traditional “sick visit” model. By focusing the AWV on preventive screening, safety issues (eg, falls), and social needs (eg, food insecurity, transportation), patients' qualities of life can be enhanced. Setting up a system within your practice that involves contributions from all members of the care team will maximize both patient benefit and practice reimbursement for this important work.