Download Annual Wellness Visit - Common Problems List Handout

Annual Wellness Visit
Common Problems List
Corresponding providermissed component(s)
AWV-required components
1.
Establishment or documented update of an individual’s medical and family
history.
1.
Establishment or documented update of an individual’s family
history.
2.
Establishment of a list of risk factors and conditions for which primary,
secondary, or tertiary interventions are recommended or are underway for the
individual, including any mental health conditions or any such risk factors or
conditions that may have been identified through an IPPE, and a list of
treatment options and their associated risks and benefits.
2.
Establishment or update of a list of risk factors and
conditions…and a list of treatment options and their associated
risk and benefits.
3.
Establishment of a list of current providers and suppliers that are regularly
involved in providing medical care to the individual.
3.
Establishment or documented update of a list of current
providers and suppliers that are regularly involved in providing
medical care to the individual.
4.
Establishment of a written screening schedule for the individual, such as a
checklist for the next 5 to 10 years, as appropriate, based on recommendations of
the USPSTF and the ACIP, as well as the individual’s health status, screening
history, and age-appropriate preventive services covered by Medicare.
4.
Establishment or documented update of a written screening
schedule for the individual…as well as the individual’s health
status, screening history, and age-appropriate preventive
services covered by Medicare.
5.
Review of an individual’s potential risk factors for depression, including current
or past experiences with depression or other mood disorders, based on the use of
an appropriate screening instrument for persons without a current diagnosis of
depression, which the health professional may select from various available
standardized screening tests designed for this purpose and recognized by
national medical professional organizations.
5.
Review of an individual’s potential risk factors for depression…
based on the use of an appropriate screening
instrument…which the health professional may select from
various available standardized screening tests…
6.
Review of an individual’s functional ability and level of safety
based on direct observation, or the use of appropriate screening
questions or a screening questionnaire.
7.
Detection of any cognitive impairment that the individual may
have.
6.
Review of an individual’s functional ability and level of safety based on direct
observation, or the use of appropriate screening questions or a screening
questionnaire, which the health professional may select from various available
standardized screening tests designed for this purpose and recognized by
national medical professional organizations.
7.
Detection of any cognitive impairment that the individual may have.
Annual Wellness Visit
Common Problems - #1
Component/Requirement
Establishment or documented
update of an individual’s medical
and family history.
1.

More often, providers fail to address or
update a member’s family medical history.

Family medical history must include, at a
minimum, the following:


Medical events in the beneficiary’s parents and
any siblings and children, including diseases
that may be hereditary or place the beneficiary
at increased risk.
Sometimes, providers fail to include a
comprehensive individual medical history.

Personal medical history must include, at a
minimum, the following:


Past medical and surgical history, including
experiences with illnesses, hospital stays,
operations, allergies, injuries and treatments
Use of or exposure to medications and
supplements, including calcium and vitamins.
Example
 Acceptable provider
documentation:

“Past medical history, family
history and current medications
reviewed. This includes history of
Angina, Coronary artery
disease...and cancer. Family history
includes hypertension, diabetes
mellitus, and her father and brother
had coronary artery disease and
cerebrovascular incidents. Further
family history unknown by patient.”
 Provider further lists details of
patient history and past diagnoses,
hospital stays, and surgeries,
which are all required for this
component, under Past Medical
History & Assessment/Plan.
Common Problems - #2
Component/Requirement
2.
Establishment or update of
a list of risk factors and
conditions…and a list of
treatment options and
their associated risk and
benefits.
 Providers lack documenting a
comprehensive list of risk factors
(i.e.: social risks, behavioral risks,
psychological risks, etc)
 While providers generally document
well on a member’s current
conditions list, they often do not
discuss or list risks and benefits to
treatment options.
Example

Acceptable provider documentation (one patient):

“Pathophysicology of diabetes discussed with patient.
Diabetes with controlled elevated sugars increases risk to
patient with damage to peripheral vascular disease with
early presentation of loss of sensations and to pin
involving especially lower exterminates. The damage to
blood vessels in the lower extremities predisposes patient
to possible gangrene, poor wound healing and increase
risk for infections and in some complicated advance cases
may result in amputations of extremities. The underlying
problem is that high blood sugars is a cause for vasculitis,
atherosclerosis, and destruction to blood vessels not only
to the distal extremities such as the legs but to all blood
vessels including the cerebral arteries, coronary arteries,
rental arteries, retinal eye blood vessels with increased
risk towards early age onset of catastrophic medical
problems including and not exclusive of cerebral vascular
, strokes, coronary artery disease, myocardial infarctions,
heart attack, diabetic retinopathy and blindness, diabetic
nephropathy with extensively and in detail to patient on
today's encounter…

Patient has been informed of the metabolic syndrome and
the risk factors for end organ disease which includes are
are not exclusive of….

Patient understands all risk factors and risks to failing to
control his treatment. Patient informed and instructed
that the main directive is for lifestyle modification of risk
factors and most important is for patient self participation
and self directives in his active role in diabetes prevention
and management.”
Common Problems - #3
Component/Requirement
3.
Establishment or
documented update of a
list of current providers
and suppliers that are
regularly involved in
providing medical care to
the individual.
 Providers will often document the
member’s pharmacy and DME
suppliers, but lack documenting
the other (oftentimes specialized)
providers involved in his/her care.
Example
 Acceptable provider documentation:
 “Member is also being followed by
Dr. R. for interventional pain
management and Dr. H. recently for
neurology.”
 “Medication list reviewed and
reconciled on 2/21/13.” (date listed =
DOS)
 Acceptable documentation to address
no new updates:
 “The patient is not using any durable
medical equipment, seeing any
other allied health care providers, or
taking any supplements outside of
the current medication list.”
Common Problems - #4
Component/Requirement
Establishment or
documented update of a
written screening schedule
for the individual…as well as
the individual’s health status,
screening history, and ageappropriate preventive
services covered by Medicare.
4.

Failure to complete includes one or more
of the following components:



Providers will verbally establish a
screening schedule, but do not
appropriately document the schedule.
Providers do not include the member’s
screening history.
Providers do not include Medicarecovered preventative services in
schedule.
Example

Provider example of acceptable vaccine schedule:
Common Problems - #5
Component/Requirement
5.
Example
Review of an individual’s
potential risk factors for
depression… based on the
use of an appropriate
screening
instrument…which the
health professional may
select from various
available standardized
screening tests…
 CMS example for depression
 Providers do not document the use
 Acceptable documentation:
 “Member screened – no risk
factors at this time for
depression.”
of a screening tool and/or the
member’s risk factor for depression.
screening (only acceptable as
documentation when fully
completed):
Common Problems - #6
Component/Requirement
6.
Review of an individual’s
functional ability and level
of safety based on direct
observation, or the use of
appropriate screening
questions or a screening
questionnaire…
 Documentation must address, at a
minimum, the following topics:




Ability to successfully perform ADLs
Fall risk
Hearing impairment
Home safety
Example
 Provider example of
acceptable documentation:
 “ADLs: Capable
Fall risk: Minimal
Hearing impairment: None
Home Safety: Safe
End-of-life Planning:
Discussed and information
given”
Common Problems - #7
Component/Requirement
7.
Detection of any cognitive
impairment that the
individual may have.
 Providers fail to document their
process of detection and level of
member impairment.

The Alzheimer's Association Medicare
Annual Wellness Visit Algorithm for
Assessment of Cognition includes
review of patient Health Risk
Assessment (HRA) information,
patient observation, unstructured
queries during the AWV, and use of
structured cognitive assessment tools
for both patients and informants.
Example
 Acceptable provider
documentation examples (with
and without impairment):
 “Mini Mental Status Examination
is normal at 30/30.”
 “Patient dementia (which is stable
at the baseline) and memory loss
are progressing slowly. The
memory loss is described as
inability to recall short term, how
to get dressed, how to shower,
recent events. She has no mental
needs now. Discussed importance
of living will – daughter will bring
a copy at next appointment.”