If a patient has been covered by Medicare Part B for more than 12 months, odds are they’re covered for an annual wellness visit (AWV). Distinct from a regular physical, the annual wellness visit is a form of preventive care targeting patients aged 65 and older—a demographic now including 18% of the US population.
An annual wellness visit is effective at identifying the complex health concerns associated with aging—especially in areas a regular physical exam might miss, such as addressing cognitive decline. Making a Medicare annual wellness visit a part of routine healthcare is a great step toward closing the gap in cognitive care planning and bringing brain health to the forefront in care provision.
Giving patients the opportunity and tools to talk about cognitive health is the first step toward integrating cognitive care planning into regular care provision. Below, we cover what physicians need to know about the Medicare annual wellness visit as preventive care—and how to incorporate brain health into primary care practice.
Key Components of a Medicare Annual Wellness Visit
Annual wellness visits focus on prevention, screening, and health education in areas of wellness like cognitive function, mental health, and lifestyle factors. In so doing, they help medical professionals to provide personalized health advice on health topics that can sometimes be overlooked.
Below, we go into some of the focal points of an annual wellness visit and why they’re important for preventive care. Be sure to refer to the list of Medicare covered services for an annual wellness visit for even more ways to prioritize preventive care.
Health Risk Assessment
A health risk assessment helps to gather information about health factors that patients might not otherwise share with their primary care provider. The questionnaire can be completed at home or in the clinic. It asks patients about external risk factors—environmental factors, for example—and internal risk factors—like emotional wellbeing, habit-related and lifestyle risk factors, and social risk factors.
Examples of helpful information an health risk assessment can uncover include:
- Nutritional habits
- Immediate health concerns
- Coping with emotions
- Substance use and other behavioral risks
- Social activities and needs
- Physical activities
New to health risk assessment guidelines in 2024 is the implementation of a Social Determinants of Health Risk Assessment, which may help guide the health risk assessment process.
Functional Ability Assessment
Assessing a patient’s functional ability is crucial for understanding their health status and ability to perform instrumental activities of daily living. A functional assessment may be required for certain referrals, including for community-based services, medical equipment, preventive counseling services, and other medical care.
A functional ability assessment may measure:
- Major mobility, such as walking and operating mobility aids
- Sensory activities, such as sight and hearing
- Cognitive ability, from memory recall to financial management ability
- Executive function, such as hygiene and making light meals
Activities of daily living may be impaired by severe cognitive deficits, which can also be measured directly. We'll cover that soon
Medical and Family History
Medical and family history are important aspects of annual physicals too. That’s why physicians will collect information about current medications, treatments, and other healthcare providers, as well as any known family medical history when conducting an annual wellness visit.
New aspects of a patient’s medical history may emerge or become relevant when preventive care concerns—like cognitive health, mental health, and potential barriers to health in the future—are made a priority.
Ways to bring out new history details can include:
- Asking about specific symptoms. For example, a patient may not be able to say whether or not their mother had Alzheimer’s, but they may be able to identify that their mother suffered confusion late in her life.
- Asking similar questions in different iterations. For example, start symptom-based, then move to behavior-based. A patient may not say their father suffered from depression, but he might have frequently withdrawn from family and social situations.
- Asking contextualizing questions. Is a patient’s tendency toward falls due to stairs in the house, walking on icy sidewalks, inappropriate shoes, or a more severe mobility issue? Finding answers to this question could be key to fall prevention.
Advance Care Planning
Some patients may need help appointing someone to make their medical decisions in the event they’re no longer able to make those decisions themselves. Advance care planning helps patients take the needed steps to securing their future medical wellbeing.
Advance care planning may involve:
- Making note of a patient’s end-of-life care wishes
- Identifying a health proxy who will step in for the patient when the time comes
- Locating and helping patients to fill out the relevant forms for medical orders
- Asking patients if they want to update their advance care plan when circumstances change
Get a complete guide to what’s included in advance care planning. Read Advance Care Planning: Advance Directives for Health Care
Personalized Prevention Plan
Just as preventive care takes many forms, a personalized prevention plan should be multi-pronged and tailored to each patient’s individual needs. These plans should cover:
- Primary prevention methods, including regular vaccinations
- Secondary prevention methods like mammograms, colonoscopies, blood pressure measurements, cognitive impairment testing, and similar early-detection screenings
- Tertiary prevention methods like medications to address early risk factors for a condition, or check-ins on patient habits and lifestyles, such as exercise and nutrition
Screenings
Screenings are some of the most integral preventive services. The earlier a condition is detected, the earlier treatment and interventions can be applied.
Screening for cognitive function, mental health, progressive diseases, cancer, and more ensures that a health care team can guide patients through personalized treatment plans earlier and more effectively. These plans might involve lifestyle changes, prescription medications, counseling, enrollment in clinical trials, care planning, or countless other measures that can improve their quality of life—and maybe even their life span.
Assessing Cognitive and Mental Health During an Annual Wellness Visit
An annual wellness visit is an ideal time to implement cognitive function screening. The earlier cognitive decline is detected, the earlier changes and treatments can be implemented that are more likely to slow its progression.
Cognitive assessments take many forms. Physicians may be familiar with the MMSE, MoCA, SLUMS testing model, and others. These are common tools for detecting severe impairment, but provide only simplistic results, and pen-and-paper testing can be burdensome to administer during an annual wellness visit, when time is short.
Computerized cognitive testing has changed cognitive testing. Modern digital platforms are making it easier to incorporate detailed cognitive and mental health screening into annual wellness visits.
One 2019 paper identified several advantages offered by computerized cognitive testing over pencil-and-paper models, including:
- Patient comfort: Computerized tasks are shorter, with automatically adjusting difficulty levels to reduce patient frustration on the fly—an important consideration in older or impaired populations.
- Automatic administration features: Patients can complete practice questions to make sure they understand how the system works before beginning, increasing reliability of testing and decreasing the need for trained staff to administer tasks. Many computerized tasks can even be taken at home before a visit.
- Ease of scoring and interpretation: Results can be automatically scored then collected in easy-to-read reports that are designed to be easy for practitioners and patients alike to understand.
- Greater sensitivity: Measuring performance with millisecond accuracy can lead to results that detect even subtle cognitive decline, increasing the possibility that emerging deficits will be identified as early as possible.
- Comparisons with norms and baselines: Results can be compared against enormous normative databases, instantly contextualizing patient performance by comparing them to age-matched norms. Personalized baselines can also be gathered on the first annual wellness visit, and clinicians can automatically be alerted when a significant decline from baseline is detected.
Case Study: GT Healthcare is a mental and behavioral health clinic that uses computerized cognitive assessment and mental health screenings—including the GAD-7 measure for anxiety, the PHQ-9 measure for depression, and the perceived stress scale—led to data-driven care that has aided in clinical decision-making overall.
Preparing Patients for an Annual Wellness Visit
Familiarizing patients with screening tools and medical forms starts with healthcare providers being familiar with them themself. Before the appointment, consider:
- How will you assess cognitive health?
- Which screening tools, if any, will you use? In what format?
- How can patients prepare for screenings?
- Which forms and processes are involved in helping patients with advance care planning?
- How can you communicate with your patients about these, and other, key wellness concerns?
Bear in mind that communication can begin before the annual wellness visit! Making patients aware of the purpose of the wellness visit—and the importance of cognitive health—may give patients time to reflect on these aspects of their health before the visit, and provide healthcare professionals with more considered answers.
Billing and Coding Considerations
Imagine that a wellness visit with a patient has identified a potential cognitive impairment. Based on the patient’s level of confusion or concern, the physician decides to book a follow-up appointment to screen cognitive function more thoroughly.
How do you bill it?
According to the American Academy of Family Physicians, the billing codes used for annual wellness visit services are:
- GO438 for the initial visit
- GO439 for a subsequent visit
Advance care planning is also an optional element of an annual wellness visit.
If the physician provides an advance care plan as part of an annual wellness visit, it is generally billed under:
- CPT code 99497 for the first 30 minutes of face-to-face planning and discussion
- CPT code 99498 for each additional 30 minutes
Though screening for cognitive impairments is an integral part of the annual wellness visit, a follow-up visit dedicated to cognitive care planning is generally billed separately with CPT code 99483.
For more on Medicare billing and coding for annual wellness visits generally and specific tools for what’s covered in an annual wellness visit, check out the Centers for Medicare & Medicaid Services (CMS) website. The CMS website also provides detailed information on the billing codes to use for cognition-specific visits and services.
Note that the CMS website is regularly updated and warns when updates have been applied. Reimbursement is not guaranteed and may also vary depending on state, type of practice, etc. Check back regularly to stay up to date on Medicare policy changes.
Improving Cognitive Care with the Annual Wellness Visit
Medicare annual wellness visits can offer the health care provider—and patients—critical opportunities for intervention on complex health concerns like cognitive function. We know that early intervention is one of the ways to ensure better quality of life among dementia patients, which makes cognitive screening and assessment an essential part of the annual wellness visit.
With Creyos, cognitive assessment has now been made even easier. Scientifically-validated, computerized tests that offer longitudinal tracking and easy reassessment provides practitioners and patients alike ready access to data on cognitive performance—including how patients compare to others in their age group.
This post was edited by Mike Battista, Director of Science and Research at Creyos (formerly Cambridge Brain Sciences).