1. During the Welcome to Medicare visit, after performance and/or discussion of each of the required components, provide appropriate education, counseling, and referral for other preventive services based on the components. Develop a written plan for screenings and other preventive services and provide it to the patient.

2. When separately identifiable and medically necessary services or procedures are provided at the same time as an Annual Wellness Visit, Medicare may not pay for the additional service. For reimbursement, provide the additional CPT code with modifier 25, along with documentation indicating why the additional service was medically necessary and reasonable to manage an illness or injury or to improve function.

3. Screen adults ages 65 and older for fall risk at least annually.

4. In performing home safety screening for older adult patients, take a history (including caregivers if needed) to assess ability to perform activities of daily living and instrumental activities of daily living, assess mobility and fall risk, and perform a physical examination (as needed) and a drug review. In addition, evaluate the home environment and review social circumstances (eg, social support, access to daily needs such as groceries and drugs) and financial resources.

Resources

1. Strength of Evidence: SORT C

   Source: Centers for Medicare & Medicaid Services, reference 8

Website: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html

2. Strength of Evidence: SORT C

   Source: Centers for Medicare & Medicaid Services, reference 26

Website: https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal11.pdf

3. Strength of Evidence: SORT C

   Source: American Geriatrics Society/British Geriatrics Society, reference 68

Website: https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2010.03234.x

4. Strength of Evidence: SORT C

   Source: UpToDate, reference 42

Website: https://www.uptodate.com/contents/comprehensive-geriatric-assessment