Sep-Oct 2012 Table of Contents


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Fam Pract Manag. 2012 Sep-Oct;19(5):10.

Medicare annual wellness visit health risk assessment

As part of the annual wellness visit (AWV), Medicare requires that we establish “a list of risk factors and conditions for which relevant primary, secondary, and tertiary interventions are underway … and a list of treatment options and their associated risk and benefits.” What should I write in my note to meet this requirement? Is it OK to use check boxes? I assume the risk factors should focus on well-being – not on chronic comorbidities like hypertension and diabetes, which are addressed separately during my simultaneously billed evaluation and management visit.

Response: Your documentation should focus on the 17 risk factors that the Centers for Medicare & Medicaid Services has identified for use in health risk assessments and should include your related recommendations or plans for follow-up care. The risk factors are physical inactivity/lack of exercise, poor nutrition, smoking/tobacco use, excessive alcohol consumption, high blood pressure, high blood glucose, high total cholesterol, being overweight/obese, inappropriate use of clinical preventive services, depression, high stress, lack of general well-being, burden of providing care giving, social isolation, lack of motor vehicle/home safety, falls (preventable accidents), and polypharmacy/medication issues. Yes, you may use check boxes. FPM has published a health risk assessment form and an AWV encounter form that you may find helpful.


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