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Annual Wellness Visit (AWV) Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check box if submitted Brief Description
  Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  Practitioner, nurse, and ancillary progress notes
  Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In
  Self-assessment of health status
  Demographic data
  Psychosocial Assessment
  Behavioral risks
  Documentation of pain level and activities of daily living (ADL) limitations, for example Roland Morris Disability Questionnaire.
  Instrumental ADLs (e.g. shopping, housekeeping, managing medications, handling finances)
  Review of beneficiary prior and current medical and functional conditions and comorbidities
  Depression screen
  Functional ability and level of safety (i.e. fall risk, hearing impairment, home safety)
  Functional Independent Measure (FIM) records
  History and Physical reports (include medical history and current list of medications)
  Vital sign records, weight sheets, care plans, treatment records
  Estimation of intellectual functioning, memory functioning, and orientation
  Record of mental status
  Mini mental status exam (MMSE) or similar test score
  Cognitive function
  Written screening test(s) schedule
  List of risk factors (i.e. mental health conditions treatment options and their associated risks/benefits)
  Personalized health advice (fall prevention, nutrition, physical activity tobacco-use cessation, weight loss)
  Opioid use risk factors (i.e., current prescriptions, severity of pain, treatment plan, non-opioid options, referrals as appropriate)
  Advance care planning
  Documentation supporting the diagnosis code(s) required for the item(s) billed
  Documentation to support the code(s) and modifier(s) billed
  List of all non-standard abbreviations or acronyms used, including definitions
  Other pertinent information
  Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  Signature attestation and credentials of all personnel providing services
  If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
  Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)

 

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Preventive Services webpage for more information and resources.

 

Last Updated Thu, 26 May 2022 17:07:26 +0000