Annual Wellness Visit (AWV) Documentation Requirements - JF Part B
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) | |
| 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.
- Noridian Medical Review - Automated Development System (ADS) Letter
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the Preventive Services webpage for more information and resources.
Last Updated Dec 09 , 2023
