What should be completed at the initial Medicare wellness visit?

Initial Medicare Wellness Visit Requirements

The initial Medicare wellness visit must include a Health Risk Assessment (HRA), comprehensive health history review, vital signs with height/weight/BMI, blood pressure measurement, cognitive impairment screening, depression screening, functional ability assessment, fall risk evaluation, advance care planning discussion, and creation of a personalized prevention plan with screening schedule. 1, 2

Core Required Components

Health Risk Assessment (HRA)

• Complete a standardized HRA questionnaire covering medical history, family history, current medications, lifestyle factors (diet, physical activity, tobacco/alcohol use), and social determinants of health including food security, housing stability, transportation access, and community safety 1, 2
• The HRA serves as the foundation for identifying health risks and guides all subsequent screening and evaluation 2, 3

Vital Signs and Measurements

• Measure height, weight, and calculate BMI at every initial visit 1
• Obtain blood pressure measurement at the visit 1, 4
• Consider orthostatic blood pressure measurements when clinically indicated (e.g., history of falls, dizziness, or syncope) 1

Cognitive Assessment

• Screen for cognitive impairment using a brief structured assessment tool such as the Mini-Cog, General Practitioner Assessment of Cognition, or Memory Impairment Screen 1
• Medicare specifically mandates detection of cognitive impairment as part of the annual wellness visit benefit, though the USPSTF notes insufficient evidence for routine screening 1
• This screening is particularly important for patients ≥65 years of age 1

Mental Health Screening

• Screen for depression and anxiety using validated tools 1
• Screen for disordered eating patterns when appropriate 1

Functional Assessment

• Assess functional performance and activities of daily living, particularly for patients ≥65 years of age 1
• Evaluate mobility and fall risk through history and physical examination 2, 3

Physical Examination Elements

• Conduct fundoscopic examination or refer to eye specialist 1
• Perform thyroid palpation 1
• Complete comprehensive foot examination including visual inspection for skin integrity, callous formation, foot deformity or ulcers, toenail assessment, pedal pulse evaluation, and determination of temperature, vibration or pinprick sensation with 10-g monofilament exam 1
• Perform skin examination looking for acanthosis nigricans, injection sites if diabetic, or lipodystrophy 1

Laboratory and Screening Tests

Baseline Laboratory Work

• Order complete blood count (CBC) with differential to screen for anemia, infection, and blood disorders 4
• Obtain comprehensive metabolic panel (CMP) to assess kidney function (serum creatinine and estimated glomerular filtration rate), liver function, and electrolyte balance 1, 4
• Check lipid profile (total cholesterol, LDL, HDL, and triglycerides) for cardiovascular risk assessment 1, 4
• Measure hemoglobin A1C to screen for diabetes and prediabetes, especially for patients with BMI ≥25 kg/m² or additional risk factors 4
• Obtain urinalysis with spot urinary albumin-to-creatinine ratio to screen for kidney disease 1, 4

Age-Appropriate Cancer Screenings

• Initiate or update colorectal cancer screening beginning at age 45 with options including annual FIT, colonoscopy every 10 years, CT colonography every 5 years, or flexible sigmoidoscopy every 5 years 4
• Discuss prostate cancer screening for men using shared decision-making, offering PSA testing and digital rectal examination for average-risk men starting at age 50, or age 45 for higher-risk men (African American or family history) 4

Immunization Review and Administration

• Review and update vaccination status according to age-appropriate CDC recommendations 1
• Administer annual influenza vaccine for all patients ≥6 months of age 1
• Provide pneumococcal vaccination (PPSV23) for patients ages 2-64 years with diabetes or other high-risk conditions, and for all patients ≥65 years regardless of vaccination history 1
• Offer hepatitis B vaccine series to unvaccinated adults with diabetes ages 18-59 years, and consider for those ≥60 years 1
• Review tetanus-diphtheria-pertussis, measles-mumps-rubella, human papillomavirus, and other age-appropriate vaccinations 1

Care Planning and Documentation

Personalized Prevention Plan

• Create a written personalized prevention plan that includes a 5-10 year screening schedule based on the patient's age, risk factors, and current health status 2, 3
• Document specific screening recommendations with target dates for completion 2

Advance Care Planning

• Identify surrogate decision maker and discuss advance care planning including healthcare proxy, living will, and end-of-life preferences 1, 2
• This discussion should be documented and revisited annually 2

Lifestyle Counseling

• Provide counseling on diet, physical activity, tobacco cessation, and alcohol use as part of health promotion 4, 2
• Address sleep patterns and duration, as poor sleep quality is associated with adverse health outcomes 1

Common Pitfalls to Avoid

• Do not skip cognitive screening even if the patient appears cognitively intact, as Medicare specifically requires this assessment and early detection can facilitate planning 1, 2
• Do not fail to document all required elements, as proper documentation is essential for billing and ensures continuity of care 2, 5
• Do not overlook functional assessment in patients ≥65 years, as this is a critical component for identifying geriatric syndromes 1, 2
• Allocate adequate time (typically 45-60 minutes) and consider using team-based approaches with different staff members performing different components of the evaluation to improve efficiency 2, 3
• Do not delay colorectal cancer screening beyond age 45, as guidelines have recently lowered the recommended starting age from 50 4