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Annual Wellness Visit Documentation

You'll be able to structure a compliant annual wellness visit, from health risk assessment through personalized prevention planning and appropriate coding.

What this track covers

This track covers the components of the Medicare annual wellness visit: eligibility, health risk assessment administration, cognitive screening, advance care planning conversations, and individualized screening schedules. It also addresses common documentation gaps that affect coding accuracy and quality measure performance.

What you will practice

  • Distinguish eligibility and required elements for initial versus subsequent wellness visits
  • Administer and interpret a health risk assessment, including follow-up on flagged concerns
  • Apply a standardized cognitive screening tool and determine when referral is warranted
  • Lead an advance care planning conversation and document patient wishes clearly
  • Build an individualized preventive screening schedule based on patient risk factors

Simulator scenario

A returning Medicare patient presents for a subsequent AWV with a family member expressing concern about early memory changes, requiring the clinician to navigate the health risk assessment, cognitive screening, and a sensitive care-planning conversation within the visit.

Board question topics

  • Eligibility criteria and timing rules for initial versus subsequent AWVs
  • Interpreting health risk assessment responses and required follow-up
  • Cognitive screening tools and referral thresholds
  • Documentation requirements to support advance care planning coding

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