Can I schedule a fall visit with Unjury (Unjury) alongside my Medicare Annual Wellness Visit?

Can You Schedule a Fall Visit with Injury Assessment Alongside a Medicare Annual Wellness Visit?

Yes, you can and should address fall-related injury assessment during the same encounter as a Medicare Annual Wellness Visit, as fall prevention screening is explicitly included as a reimbursable component of the Annual Wellness Visit. 1

Fall Assessment is Part of the Medicare Annual Wellness Visit

The Medicare Annual Wellness Visit specifically includes fall risk screening as a core component of the functional assessment required for all beneficiaries 65 years and older. 2, 1 This means:

• Fall prevention screening is already reimbursed as part of the Annual Wellness Visit, eliminating the need for a separate visit. 1
• The functional assessment component of the wellness visit must evaluate activities of daily living and mobility, which directly encompasses fall risk evaluation. 2
• The Centers for Disease Control and Prevention developed a specific algorithm (STEADI) to aid implementation of fall screening during these visits. 1

How to Structure the Combined Visit

When a patient presents with both a fall history and is due for their Annual Wellness Visit, integrate the fall assessment into the wellness visit framework:

Core Fall Assessment Components to Include

• Screen all adults 65 and older annually for fall history or balance impairment as recommended by the American Geriatrics Society and British Geriatrics Society. 1
• Document the number of falls in the past year—the CDC algorithm recommends multifactorial intervention for patients with two or more falls or one fall-related injury. 1
• Assess key fall risk factors including gait and balance difficulties, orthostatic hypotension, vision problems, medication review (especially psychoactive medications), and home environment hazards. 1
• Perform cognitive assessment using validated tools like Mini-Cog (sensitivity 76%, specificity 89%), as cognitive impairment increases fall risk. 2

Injury Assessment if Fall Occurred

If the patient has sustained a recent fall with potential injury:

• Evaluate for "occult" traumatic injuries that may present without classic signs in geriatric patients, including blunt head trauma, spinal fractures, and hip fractures. 3
• Assess time spent on floor or ground, loss of consciousness, near-syncope, orthostasis, and melena. 3
• Review specific comorbidities that increase fall risk: dementia, Parkinson's disease, stroke, diabetes, hip fracture history, and depression. 3
• Examine visual or neurological impairments such as peripheral neuropathies. 3

Billing and Documentation Strategy

Use the -25 modifier CPT code when addressing acute fall-related injuries during the wellness visit. 3 This modifier allows for same-day treatment of issues identified during the preventive visit that would otherwise require a separate encounter, representing an important window of opportunity for timely intervention. 3

Multifactorial Intervention Plan

For patients identified at increased fall risk (which is 21% of screened older adults), implement a patient-centered fall prevention plan: 4

• Exercise prescription focusing specifically on balance, strength, and gait training. 1
• Vitamin D supplementation with or without calcium. 1
• Medication management, particularly reviewing and reducing psychoactive medications. 1
• Home environment modification with home safety assessment referrals. 3, 1
• Management of postural hypotension, vision problems, foot problems, and appropriate footwear. 1

Follow-Up and Referrals

• Expedited outpatient follow-up for patients discharged from the encounter should include home safety assessments. 3
• Consider admission if patient safety cannot be ensured in the community setting. 3
• Physical therapy and occupational therapy referrals should be made for patients with significant fall risk or injury. 3
• Schedule 2-week follow-up to assess adherence to fall prevention plans (studies show 74% adherence for gait/strength/balance interventions and 67% for home safety modifications). 4

Critical Pitfalls to Avoid

• Do not miss the opportunity to discuss falls during the wellness visit—fewer than half (48%) of Medicare beneficiaries who fall report talking to a healthcare provider about it, and only 60% of those receive fall prevention information. 5
• Do not conduct a brief physical examination instead of comprehensive preventive services—mental health screening, cognitive assessment, and functional evaluation are mandatory components. 2
• Do not overlook medication review—polypharmacy and high-risk medications are major modifiable fall risk factors that must be addressed. 3
• Do not assume a straightforward cause—ask yourself "if this patient was a healthy 20-year-old, would they have fallen?" If no, conduct a comprehensive assessment of underlying causes. 3