Initial Medicare Annual Wellness Visit Checklist
HPI/Family /Social History
Perform patient reported Health Risk Assessment
Staying Healthy Assessment – Senior version
Medical and Family History – By history – often in Cerner
Current Providers List - Document
Medications List – In Cerner
Offer Advanced Care Planning at the patient’s discretion – POLST, Advanced Directive
Review Opiods, evaluate pain, screen for OUD if needed
SBIRT form– (Screening, Brief Intervention, Referral to Treatment)
Measure Height Weight Vitals, BMI, Vision - Routine
Assess and document Cognitive Function by any of the following;
MOCA or other cognitive test
Assess Depression/Mood Disorders Risk (On SBIRT)
PHQ-2 or PHQ-9
Assess Functional Ability or Safety (Fall risk) - (On Staying Healthy Assessment)
Direct Observation or screening tool in all of the following areas;
· Ability to perform ADLs (On Staying Healthy Assessment)
Do you have problems with cooking, cleaning and groceries?
· Fall Risk – (On Staying Healthy Assessment)
· Get up and Go Test
Initial Assessment - From sitting position, stand without using their arms for support. • Walk10 feet, turn, and return to the chair. • Sit back in the chair without using their arms for support. Individuals who have difficulty completing the above in less than 10 seconds or demonstrate unsteadiness performing this test require further assessment.
Follow-up Assessment - Ask the person to: • Sit. • Stand without using their arms for support. • Close their eyes for a few seconds, while standing in place. • Stand with eyes closed, while you push gently on his or her sternum. • Walk a short distance and come to a complete stop. • Turn around and return to the chair. • Sit in the chair without using their arms for support
Follow-Up Assessment Observations
• Is the person steady and balanced when sitting upright? Yes † No †
• Is the person able to stand with the arms folded? Yes † No †
• When standing, is the person steady in narrow stance? Yes † No †
• With eyes closed, does the person remain steady? Yes † No †
• When nudged, does the person recover without difficulty? Yes † No †
• Does person start walking without hesitancy? Yes † No †
• When walking, does each foot clear the floor well? Yes † No †
• Is there step symmetry, with the steps equal length and regular ? Yes † No †
• Does the person take continuous, regular steps? Yes † No †
• Does the person walk straight without a walking aid? Yes † No †
• Does the person stand with heels close together? Yes † No †
• Is the person able to sit safely and judge distance correctly? Yes † No †
• Is the person obviously fearful or anxious during assessment? Yes † No †
· Hearing impairment – Whisper test, formal hearing test
The Whisper Test
Stand 1-2 feet behind patient so they can’t read your lips.
Instruct patient to place one finger on tragus of left ear to obscure sound.
Whisper word with 2 distinct syllables towards patient's right ear.
Ask patient to repeat word back.
· Home safety
Have you fallen in the past year?
Do you feel unsteady when standing or walking?
Are you worried about falling?
Brief Assessment – consider physical therapy referral or PM&R referral
Gait, strength, balance tests
Identify medications taken that increase falls risk
Ask about home hazards
Consider measuring orthostatic blood pressure
Check visual acuity
Assess feet and footwear
Assess Vitamin D intake
Identify comorbidities that increase falls
Assessment and Plan
Identify a Problem List and Risk Factors and your treatment/interventions.
Provide a Written Health Maintenance checklist for the next 5-10 years (Eg. USPTF)
Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs.
Include referrals to educational and counseling services or programs aimed at:
Community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including:
o Fall prevention
o Physical activity
o Tobacco-use cessation
o Weight loss
Refer as needed for addiction services.
G0438 – Initial Annual wellness visit; includes a personalized prevention plan of service, within the first 12 months of starting Medicare
G0439 – Subsequent Annual wellness visit, includes a personalized prevention plan of service, at least 12 months after the initial wellness visit
Can use any diagnosis but need a diagnosis – (Well Adult or similar would be a good choice)
You can also bill for screening tests (colon cancer, breast cancer, dexa, vaccines etc.) under this visit or at a future visit, does not need to be a screening, be sure to use the diagnosis code for each screening test Eg. Screening for malignant neoplasm colon, screening for malignant neoplasm breast, post-menopausal state, need for vaccination)