What is the correct protocol for a Medicare annual wellness visit?

Medicare Annual Wellness Visit Protocol

The Medicare Annual Wellness Visit requires completion of a standardized Health Risk Assessment, physical measurements (height, weight, BMI, blood pressure), cognitive screening with a validated tool like the Mini-Cog, depression screening, functional assessment, medication review, and development of a personalized prevention plan with appropriate referrals. 1, 2

Distinguish Between Initial and Subsequent Visits

Medicare offers two types of wellness visits with different billing codes and requirements:

• Initial Wellness Visit (code G0438): For patients who have never had a Medicare wellness visit 3
• Subsequent Annual Wellness Visit (code G0439): For patients returning for annual follow-up 3

Both visits share core components but the initial visit is more comprehensive 2, 4.

Required Core Components

Health Risk Assessment Questionnaire

• Complete a standardized HRA covering medical history, family history (including autoimmune disorders and complications), current medications, lifestyle factors, and social determinants of health 1, 2
• Assess food security, housing stability, transportation access, financial security, and community safety 1

Physical Measurements

• Measure height, weight, and calculate BMI 1, 2
• Obtain blood pressure measurement 1, 2

Cognitive Assessment

• Use the Mini-Cog test as the preferred screening tool - it takes only 2-4 minutes to administer with 76% sensitivity and 89% specificity for detecting dementia 1, 5
• The Mini-Cog combines three-item word recall and clock drawing test 5
• This screening is specifically reimbursed by Centers for Medicare & Medicaid Services as part of the AWV 6
• Common pitfall: Do not skip cognitive screening even if the patient appears cognitively intact, as Medicare specifically requires this assessment 2

Depression and Mental Health Screening

• Screen for depression using validated tools such as PHQ-2 or PHQ-9 1, 2
• Screen for anxiety when appropriate 2
• Common pitfall: Mental health screening is critical and should not be neglected 1

Functional Assessment

• Evaluate activities of daily living and mobility, particularly important for patients 65 years and older 1, 2
• Common pitfall: Do not overlook functional assessment in patients ≥65 years, as this identifies geriatric syndromes 2

Medication Review

• Assess medication-taking behavior, potential rationing of medications, medication intolerance, and side effects 1
• Review all current medications including prescription and over-the-counter 2

Preventive Screenings and Laboratory Tests

Age-Appropriate Cancer Screenings

• Colorectal cancer screening: Begin at age 45 (not age 50 as previously recommended) 2
• Cervical cancer screening: Pap smear every 3 years, or cytology plus HPV testing every 5 years for women aged 30-65 1
• Breast cancer screening: Clinical breast examination annually for women >19 years; mammography biennially for women aged 50-74 1
• Prostate cancer screening: Discuss with men using shared decision-making 2

Laboratory Testing

• Complete blood count (CBC) with differential 2
• Comprehensive metabolic panel (CMP) 2
• Lipid profile (total cholesterol, LDL, HDL, triglycerides) if not done within the past year 1, 2
• Diabetes screening with A1C if not available within past 3 months 1
• Bone health assessment (calcium, vitamin D, phosphorous) when appropriate for postmenopausal women 1

Immunizations

• Review and update vaccination status according to CDC recommendations 2
• Administer annual influenza vaccine 2
• Provide pneumococcal vaccination (PPSV23) for appropriate patients 2

Behavioral and Social Assessment

Substance Use Screening

• Screen for tobacco, alcohol, and substance use with appropriate counseling 1

Lifestyle Assessment

• Assess physical activity and sleep behaviors, including screening for obstructive sleep apnea 1, 2
• Review eating patterns and weight history 1

Personalized Prevention Planning

Care Plan Development

• Develop a personalized prevention plan based on identified risk factors and health needs 1
• Provide counseling on diet, physical activity, tobacco cessation, and alcohol use 2
• Make referrals to health education and prevention counseling services as needed 1

Advance Care Planning

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

Special Considerations for Women

• Perform BRCA risk assessment by asking about family history suggestive of increased risk for deleterious mutations, with referral for genetic counseling if risk factors identified 1
• Counsel about risk-reducing medications for women at increased risk for breast cancer 1
• Prioritize osteoporosis screening for postmenopausal women 1

Follow-Up After Positive Screening Results

If Mini-Cog is Positive

• Trigger comprehensive cognitive evaluation including functional status assessment, neuropsychiatric symptoms evaluation, medical history and physical examination, and laboratory testing to rule out metabolic or infectious causes 5
• Perform comprehensive cognitive testing using MoCA or MMSE 5
• Evaluate for type and severity of dementia, comorbid conditions, and safety concerns including driving and medication management 5

Implementation Strategies

• The AWV can be delivered by pharmacists or other trained healthcare team members, not just physicians, which improves practice efficiency and income 7, 3
• Post-visit follow-up protocols enhance quality metric satisfaction rates 7
• The visit provides opportunity to close gaps in preventive care, strengthen patient-provider relationships, and improve quality metrics 8
• Common pitfall: Avoid substituting brief physical examinations for the comprehensive preventive services required by Medicare 1
• Common pitfall: Do not focus solely on physical health while neglecting behavioral and social aspects 1