Medical Risk Adjustment Toolkit

Annual Wellness Visits, Routine Physical Exams & Office Visits Coding & Documentation Guide

As organizations transition towards value-based payment models, clinics can transform best practices on preventive care and screening services that treat complex, high-risk patients. Medicare Annual Wellness Visits (AWVs), routine physical exams and general office
visits provide opportunities to ensure patients remain as healthy as possible. Not only do these types of encounters encourage multiple gaps in care closure, but they also ensure the needs of chronically ill patients are met. The following coding and documentation tips and charts provide procedural/service-based coding information and feature patient encounter types.

The Medicare AWV is an individualized plan to help improve patient engagement and promote preventive care. A typical AWV includes review of a patient’s medical history, family medical history, potential risk factors for preventable diseases, review of Health Risk Assessment questionnaire, review of providers and prescriptions, and signs of cognitive impairment. Additional services, such as lab work performed during the AWV, are not included and must be billed separately. Additional preventive services, such as colorectal cancer screenings, are reviewed and potentially scheduled during the AWV. The AWV is a covered benefit
for Medicare patients over the age of 65 and can be performed every 12 months.

An annual physical examination is an extensive exam similar to Medicare’s AWV service. However, annual physical exams include additional services, such as vital signs check, lung exam, head and neck exam, abdominal exam, neurological
exam, and reflex check. Blood work and lab tests are included in annual physical exams, but not within an AWV. Although Medicare does not cover routine physical examinations, some Medicare Advantage plans do offer additional services to cover physical exams. The majority of private insurance plans offer various patient coverage for annual physicals. 

Documentation Tips:

  • Include Health Risk Assessment patient responses when performing AWV.
  • Create patient’s medical and family history by documenting events, including medications and supplement use, when performing AWV.
  • Document height, weight, BMI and blood pressure during both AWV and annual physical exam.
  • Review and document potential risk factors and assess functional status when performing AWV.
  • Document chronic conditions using the Monitor, Assess, Evaluate and Treat (M-E-A-T) tool when performing both AWV and annual physical exam.
  • Document past illnesses, surgeries, medications, allergies, family and social histories, status of chronic conditions, blood pressure, height, weight, BMI, outstanding screenings needed, counseling guidance, physical activity, healthy weight, tobacco use, mental health, immunizations, alcohol and drug use, and sexual behavior during both services to provide a comprehensive visit.

Provider Considerations:

1. Address social determinants of health (SDOH) during both services to provide a comprehensive assessment of the patient.

2. Provider documentation during both services should include guidance on screenings ordered or offered, even if the patient chooses to decline.

3. Both services should address recommended preventive services and identify chronic conditions the patient likely has on an
annual basis. Both services apply to medical risk adjustment methodology and can help provide a more accurate picture of a patient’s current health status through diagnostic coding and documentation.

  • Include Evaluation and Management (E/M) services provided along with the AWV. These can be reported with the specified CPT code and modifier -25.
  • If performed, Advance Care Planning (ACP) can be billed in addition to AWV service with the use of modifier -33 to prevent cost-sharing to the patient.
  • Ensure modifier -25 is used if separate E/M service is performed by the same physician on the same day as the preventive service is provided.
New COVID-19 Vaccine and Treatment Resources AvailableLearn More