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.