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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.”