What components should be included in a Medicare wellness visit?

Medicare Wellness Visit Components

Medicare wellness visits must include a comprehensive Health Risk Assessment, vital signs measurement, cognitive and depression screening, functional assessment, preventive service review with personalized prevention planning, and advance care planning discussions. 1, 2

Required Core Components

Health Risk Assessment (HRA)

• A standardized HRA questionnaire covering medical history, family history (including autoimmune disorders), current medications, lifestyle factors, and social determinants of health must be completed. 3, 2
• Social determinants assessment should specifically address food security, housing stability, transportation access, financial security, and community safety. 3, 1

Physical Measurements and Vital Signs

• Height, weight, BMI calculation, and blood pressure determination are mandatory at every visit. 3, 1, 2
• Blood pressure should be measured at every encounter. 3, 4

Cognitive Assessment

• Cognitive screening using validated tools such as the Mini-Cog (sensitivity 76%, specificity 89%), General Practitioner Assessment of Cognition, or Memory Impairment Screen is required. 1, 2
• Do not skip cognitive screening even if the patient appears cognitively intact—Medicare specifically requires this assessment and early detection facilitates care planning. 2

Mental Health Screening

• Depression screening using validated tools such as PHQ-2 or PHQ-9 must be performed. 3, 1, 4
• Screen for anxiety, diabetes distress, fear of hypoglycemia, and disordered eating when appropriate. 3, 1

Functional Assessment

• Evaluate activities of daily living and mobility, particularly critical for patients ≥65 years to identify geriatric syndromes. 3, 1, 2
• Assess disability status and use of assistive devices including physical, cognitive, vision, and auditory aids. 3

Medical History Review

Comprehensive Interval History

• Review changes in medical and family history since last visit, including complications and common comorbidities such as obesity, obstructive sleep apnea, and non-alcoholic fatty liver disease. 3, 1
• Assess medication-taking behavior including potential rationing of medications/medical equipment, intolerance, and side effects. 3, 1
• Document tobacco, alcohol, and substance use with appropriate counseling. 3, 1, 4
• Review eating patterns, weight history, physical activity, and sleep behaviors including screening for obstructive sleep apnea. 3, 1

Laboratory and Preventive Screenings

Required Laboratory Tests

• Lipid profile (total, LDL, HDL cholesterol and triglycerides) if not performed within the past year. 3, 1, 4
• A1C testing if results not available within the past 3 months. 3, 1, 4
• Complete blood count (CBC) with differential and comprehensive metabolic panel (CMP) for baseline assessment. 2, 4
• Urinalysis with spot urinary albumin-to-creatinine ratio. 3, 4
• Serum creatinine and estimated glomerular filtration rate. 3

Age and Gender-Specific Screenings

• For women aged 50-74 years: Mammography screening biennially and clinical breast examination annually. 1
• For women aged 30-65 years: Cervical cancer screening with cytology every 3 years, or cytology plus HPV testing every 5 years. 1
• For postmenopausal women: Bone health assessment including calcium, vitamin D, and phosphorous levels; osteoporosis screening. 1
• For women with family history: BRCA risk assessment with referral for genetic counseling if risk factors identified. 1
• For men aged 65-75 years who have ever smoked: Abdominal ultrasonography once for abdominal aortic aneurysm screening. 4
• For all adults ≥45 years: Colorectal cancer screening initiation or update. 2

Vaccination Review and Administration

• Review and update vaccination status according to age-appropriate CDC recommendations. 2
• Administer annual influenza vaccine for all patients ≥6 months of age. 3, 2
• Provide pneumococcal vaccination (PPSV23) for patients ages 2-64 years with diabetes or other high-risk conditions. 3, 2

Personalized Prevention Planning

Care Plan Development

• Develop a personalized prevention plan based on identified risk factors and health needs with short-term (weeks/months) and long-term (years) goals. 1, 4
• Provide health promotion counseling on diet, physical activity, tobacco cessation, alcohol use, and sleep patterns. 2, 4
• Make referrals to health education and prevention counseling services based on screening results. 1, 4

Advance Care Planning

• Identify surrogate decision maker and discuss advance care planning including healthcare proxy, living will, and end-of-life preferences. 3, 1, 2

Documentation Requirements

• Compose written records reflecting patient evaluation with detailed priorities for risk reduction and rehabilitation. 3
• Generate a written summary identifying specific areas requiring further intervention and monitoring, provided to patient and primary healthcare providers. 3

Common Pitfalls to Avoid

• Do not substitute brief sports physicals or routine examinations for the comprehensive preventive services required by Medicare. 3, 2
• Do not overlook functional assessment in patients ≥65 years—this is critical for identifying geriatric syndromes. 2
• Mental health screening is mandatory and should not be neglected. 1
• Do not focus solely on physical health while neglecting behavioral and social aspects. 1
• Do not delay colorectal cancer screening beyond age 45, as guidelines have lowered the recommended starting age from 50. 2