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:

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Brief Description
Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In
Self-assessment of health status & Demographic data
Documentation of behavioral, psychosocial, and depression risk factors
Documentation of activities of daily living (ADL) limitations (e.g. dressing, feeding, toileting, grooming, ambulation, bathing); and instrumental ADL’s (e.g. shopping, housekeeping, managing medications, handling finances)
Review of beneficiary prior and current medical and functional conditions and comorbidities
Functional ability and level of safety (i.e. fall risk, hearing impairment, home safety)
List of current patient providers and suppliers that regularly provide medical care, including behavioral health care
History and Physical reports (include medical history and current list of medications)
Vital sign records, weight sheets, care plans, treatment records
Record of mental status; cognitive function
Written screening test(s) schedule & Advance care planning
Personalized health advice (fall prevention, nutrition, physical activity tobacco-use cessation, weight loss)
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
Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
Signatures are required for medical review for the following purposes: 1) To satisfy specific signature requirements in statute, regulation, National Coverage Determination (NCD) or Local Coverage Determination (LCD); and 2) To resolve authenticity concerns related to legitimacy of falsity of the documentation
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 Mar 18 , 2025

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.