Care Model Eligibility – CMS Annual Wellness Visit

All patients who are no longer within 12 months after the effective date of their first Medicare Part B coverage period and have not received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months.

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Patient Segment Eligibility Description Data Source
All patients Patients who are no longer within 12 months after the effective date of their first Medicare Part B coverage period and have not received an AWV within the past 12 months.

Exclusions: If a patient has received an initial preventive physical examination (IPPE), they are not eligible for an AWV for the next 12 months

 Claims

  • HCPCS codes to identify previous AWV
  • HCPCS codes to identify exclusions

Care Model Implementation – CMS Annual Wellness Visit

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Time Frame Action
Trigger event Beneficiary has gone more than 12 months without an Annual Wellness Visit
Within 30 days of trigger event (flexible) Conduct initial AWV, including Personalized Prevention Plan Services (PPPS):

  • Establish individual’s medical/family history.
  • Establish list of current providers and suppliers that are regularly involved in providing medical care to the individual.
  • Measure individual’s height, weight, BMI, BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history.
  • Detect any cognitive impairment that the individual may have.
  • Review the individual’s potential risk factors for depression, including current or past experiences with depression or other mood disorders
  • Review the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire
  • Establish a written screening schedule for the individual, based on the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
  • Establish a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
  • Furnish personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.

Conduct subsequent AWV for beneficiaries who have previously received an initial AWV with PPPS:

  • Update the individual’s medical/family history.
  • Update the list of current providers and suppliers that are regularly involved in providing medical care to the individual.
  • Measure the individual’s weight, BP, and other routine measurements as deemed appropriate, based on the individual’s medical/family history.
  • Detect any cognitive impairment that the individual may have.
  • Update the written screening schedule for the individual.

Update the list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual.

Care Model Compliance – CMS Annual Wellness Visit

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Intervention Intervention Description Data Source
Conduct AWV The AWV will include the establishment of, or update to, the individual’s medical and family history, measurement of his or her height, weight, body-mass index (BMI) or waist circumference, and blood pressure (BP), with the goal of health promotion and disease detection and fostering the coordination of the screening and preventive services that may already be covered and paid for under Medicare Part B.

See detailed information on Care Model: Annual Wellness Visit – Implementation.

 Claims:

HCPCS codes to identify AWV billing