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annual wellness visit hpi

HPI Template: General/Well exam

Yo. What’s up?

I’ve honestly wanted to do a more specific post like this because it is highly searched, but I’ve also been dreading doing it.

Simply put: writing an HPI is hard. It is usually hard to find a template as everyone has their own style. Some are longer, more eloquently put and flow great. Some are short and choppy in style. It really all depends on your preferences, your provider’s preferences, and sometimes the specialty.

So, I’m going to attempt to do a general template for you. Again, most of this you just have to PRACTICE. It really is the only way to get good at HPI’s.

What is a well exam?

Ah. So glad you asked.

A well exam is usually a yearly exam for your checkups. Can be called annual exam, well exam, general medical exam, etc. Typically when you are a pediatric patient, you have many well exams in a year. For example, you will be seen at 1 week post-life, then like 1 month, 2 months, 4 months, 6 months, etc. Once you reach about the age of 2 or 3 you start seeing a pediatrician yearly. After that (especially as an adult), you should really have a comprehensive medical exam with your doctor once a year.

Now, if you have chronic conditions, you are likely going to have to see your doctor more regularly. But they can at least count one of those visits as a yearly exam which is less of a cost to your insurance.

Additionally, most adults’ jobs will give discounts if you go to your yearly exam to show you are trying to stay healthy. I don’t know why some jobs seem to care about this, but they do.

Okay back to the template

By now you should know what a SOAP note template looks like. If not, go check out my other scribe series posts. It’s all in there. If you have, I’m going to skip all the additional stuff and just focus on the HPI.

Super basic, no flare:

{First name, last name} is a {age} y/o {sex} presenting with a cc of {location if applicable} {chief complaint} which started {onset}. Symptom is described as {character/quality}, last for {duration}, and is described as a {0-10/10, severity} on the pain scale. It. {does/doesn’t} radiate to {location}, and is noted mostly at {timing}. {List of aggravating symptoms} exacerbate/aggravate {cc}. While {list of alleviating symptoms} improve {cc}. Associated symptoms include {List of associating symptoms}. {List negative associated symptoms}. There are no other concerns/complaints at this time.

It looks like this:

Mr. {Judge X} is a {55} y/o {M} presenting with a cc of {RLQ} {abdominal pain} onset {15 hours ago}. Initially, pain was around his umbilicus, but has now settled to his RLQ. It is described as {sharp}, and at first was {waxing and waning} but is now {constant}. Pain is currently rated an {8/10}. It {does not} radiate. {Hitting bumps on the car ride over} aggravated his pain. He has tried {Tylenol, Motrin, and Pepto-Bismol} without relief. Associated symptoms include {nausea, vomiting x1, low grade fever of 100.4’F at home, and chills}. {No reported hematemesis, diarrhea, hematochezia, chest pain}, DIB, or other symptoms.

Template when there are multiple complaints

So. As much as life would be really easy if there was only one complaint that someone came in with, people don’t just do that. A lot of times, they have several chronic diseases that are managed. Other times they wait a very long time before being seen, and then come in with several complaints that they would like addressed. These templates need to be a bit more broken down.

Basic, multiple complaint template:

{First name, last name} is a {age} y/o {sex} presenting for a generalized well examination.

{His/Her} first concern, {main complaint}. They first noted {his/her} {complaint} {onset}. Symptom is described as {character/quality}, last for {duration}, and is described as a {0-10/10, severity} on the pain scale. It. {does/doesn’t} radiate to {location}, and is noted mostly at {timing}. {List of aggravating symptoms} exacerbate/aggravate {cc}. While {list of alleviating symptoms} improve {cc}. Associated symptoms include {List of associating symptoms JUST FOR THIS COMPLAINT}. {List negative associated symptoms JUST FOR THIS COMPLAINT}.

You only want to add negative and associated symptoms that correlate with that complaint. This may not be a long list. That is okay.

You can then add as many similar paragraphs to additional complaints.

In regards to {his/her} {chronic condition}, they have been doing {well, poor}. They have been {compliant/non-compliant} with their medications, which include {list their medications and doses}. They have tried/incorporated {lifestyle changes} with good measure. Their last {objective finding related to this disease/condition}. {List associated symptoms if any}. {List negative associated symptoms if any}.

You can then add several similar paragraphs if they have multiple chronic conditions.

For example:

{Miss Sanchez} is a {32 y/o} {F} presenting today for a generalized well examination.

In regards to {her} {diabetes}, she has been doing {fairly well} per her reports. She has been {compliant} with her metformin and glipizide on her current regimen. She has tried to {cut out sodas and limits her caffeine intake to 1-2 coffees a day}. She additionally tries to walk around the block after work and on her lunch break. However, she has not made progress with much other changes to her lifestyle. She does not often check her sugars at home. Her last {hgb A1C was 8.0}. Today, her hgb A1C is {7.9}. She denies any {paresthesias, weight gain, eye changes, or urinary complaints}. She has not gone for her annual eye exam yet.

Things to think about per complaint:

  • Diabetes: medication compliance, diet/exercise changes, weight gain/loss, Hemoglobin A1c results (more reliable than glucose levels on a BMP), any new symptoms they are having. The three big things with diabetes is diabetic retinopathy, nephropathy, and peripheral neuropathy. Or eyes, kidneys, and tips of the extremities. They should be seen every 3 months for glucose checks, should be checking their sugars at home, should have an annual eye exam, and should have their urine monitored for protein and glucose at least yearly. Additionally, a diabetic foot exam should be performed once a year (some providers like to do it twice a year).
  • Hypertension: medication compliance, monitoring blood pressures at home, diet/exercise changes. Losing 10% of your body weight can actually resolve or improve a lot of chronic diseases (including improving diabetes and hypertension). Other things to think about include hyperlipidemia, so a yearly lipid panel check should be done as well. Overall, most of this discussion will be medication compliance and lifestyle changes.
  • Thyroid checks: The main blood test ordered is TSH, but you will also see FT3/4 also sent. Most of the patients you will see will already be on medication, and this is simply checking to make sure the medication dosage doesn’t need to be changed. As a scribe, you won’t really need to be doing much else with this information. But if the patient is being newly diagnosed, then a high TSH indicates hypothyroidism, and a low TSH indicates hyperthyroidism. Usually follow up tests such as a thyroid ultrasound would also be ordered to confirm that there isn’t anything else occurring, so add this information in if your provider likes that information in their HPI. Otherwise, the medication dosage and frequency is important along with any possible symptoms the patient is having.
  • Chronic lung complaints: Common things to add include when the last PFT was (lung function testing), last CXR, if they are on inhalers, what they are, dosage, etc; how often they are using rescue inhalers, the type of work they do, if they are exposed to smokers, if they are a smoker, things like that. Worsening symptoms include sputum production, increased coughing, and dyspnea. These patients can tend to have COPD exacerbations more frequently as the disease progresses or isn’t well controlled, and they tend to get pneumonia very easily.
  • Well Woman exam: The main thing here is when was her last exam, any prior positive HPV testing (and what it showed, such as ASCUS vs low vs high dysplasia), and if those resulted in any procedures previously. Last mammogram or ultrasound or MRI (depending on age), last menstrual period, previous pregnancies (included as GPA, or gravid, para, and abortions), age when her menstrual cycle started, if she is in menopause/when did that occur.
  • Vaccinations: These are mostly age specific. In a pediatric population, there are many more vaccinations to keep track of. In the elderly, there are a few that are important. Otherwise, you will usually see tetanus as a big one being asked in the ED regardless of the age. You basically want to know what vaccination and when/how long ago they had it.
  • Additional cancer screenings: There are a lot. For example, gynecologic screenings, breast screenings, colon cancer screenings, lung cancer screenings… you get my point. Each has a specific set of questions and age requirements. Usually your doctor will be the one to ask, you just need to put if they have or haven’t. If they have, what age the screening was done/how long ago and what the results were.

General Information for the plan

Yes, well exams tend to take a while simply because you need to have a thorough examination. And if you are just writing the note, it means more things for you to click/type out. However, not every well exam you do will be daunting. And neither will the note. Typically most people don’t have several complaints and are just there to get yearly bloodwork and a pat on the back. However, you will have people with a list of complaints/concerns and then you have a massive HPI and usually a larger plan.

But well exams aren’t just the large HPI’s. The plan is also important. General health information gets relayed here along with information for each complaint. Several of the complaints listed in the above section go over areas that need to be counseled on. You may end up discussing a lot of this or majority of this information. When one of your providers frequently has a spiel about something, I suggesting making a “dot phrase” or quick phrase. That way, you can just pull it into the note and you don’t have to re-type it all the time.

Additional things:

  • Counseling on diet and exercise.
  • Exercise prescriptions
  • RICE instructions
  • how to measure your blood pressure
  • low salt diet
  • home safety
  • General discussion about labwork/imaging
  • general discussion about what to return for/call/go to the emergency department for

Again, depending on the encounter will depend on what is brought up. Once you see a few you will start to get the hang of it. As a scribe, if you can’t pick up well and run with it you won’t make it very far. As a medical student, PA student, or nursing student, you should have enough background to trigger this knowledge to help you run with it. That is what you are being trained to do after all!

Anywho, good luck and cheers!

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March 6, 2024

Reporting a problem-oriented visit on the same day as Welcome to Medicare (G0402) or Initial and Subsequent Wellness Visit (G0438, G0439)

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  • I continue to hear that some consultants and coders don’t agree with reporting a problem oriented visit with welcome to Medicare or wellness visit
  • The 2024 Physician Fee Schedule Final Rule commented on this

What does CMS say about adding an E/M service to a Welcome to Medicare visit or annual wellness visit?

About the Welcome to Medicare visit

When you furnish a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service along with the IPPE, Medicare may pay for the additional service. Report the additional Current Procedural Terminology (CPT) code (99201–99215) with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member. [1]

About the Annual Wellness Visit

When you furnish a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service along with the AWV, Medicare may pay for the additional service. Report the additional Current Procedural Terminology (CPT) code with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member. [2]

From the 2024 Physician Fee Schedule Final Rule

And, in the 2024 Physician Fee Schedule Rule, in a discussion of initiating visits for Community Health Integration CMS says, “Further, we believe that practitioners would normally bill an E/M visit in addition to the AWV when medical problems are addressed in the course of an AWV encounter, in accordance with our manual policy providing that a medically necessary E/M visit may be billed when furnished on the same occasion as an AWV in those circumstances (Chapter 12, Section 30.6.1.1.H of the Medicare Claims Processing Manual (Pub, 100-04).” [3]

And, “We continue to believe that when an AWV involves diagnosis or treatment of injury or illness to the degree that would warrant subsequent furnishing and billing of CHI to remove barriers significantly limiting the treatment plan, in most cases, an E/M visit would be separately billed.” [4]

CMS appears to be saying that when a Medicare beneficiary requires diagnosis or treatment of an illness, they expect a separate E/M service to be reported.

[1] ABCs of the Initial Preventive Physical Exam (IPPE) , ICN 006904 April 2017 p. 5

[2] ABCs of  the Annual Wellness Visit, ICN 905706 April 2017 p. 10

[3] CMS 2024 Physician Fee Schedule Final Rule, p. 309

[4] CMS 2024 Physician Fee Schedule Final Rule, p. 313

If you’ve read anything I’ve written on this topic or watched my videos , you know my opinion:

If the physician/NP/PA treats and documents and manages an acute or chronic problem during the same encounter as a wellness visit, bill both a Welcome to Medicare or Wellness Visit on the same day (hereafter referred to in shorthand as “wellness visits”). Reviewing significant, stable chronic problems counts. The note should show that the condition was reviewed and assessed, especially if there is no change in treatment. I do add a caveat: if the information about the chronic conditions is imported/copied from a prior note with barely an update , then don’t bill for the problem-oriented visit.

One MAC’s Q&A

Q: When a patient is scheduled for a follow up visit of several chronic conditions, is it allowed for the provider to separately bill Annual Wellness Visit performed on the same day? Answer: Some chronic, stable conditions may not require assessment beyond the AWV, while others may require additional clinical examination and review or changes to the plan of care. This decision is within the realm of the performing provider’s clinical judgement. When additional history, examination and MDM is indicated to fully assess a patient’s clinical status, a separate E/M service may be performed and billed. Documentation of the E/M visit should clearly support the medical necessity of the separate service. Added 2/20/2020 Q: When is an E/M service separately payable on the same DOS as the AWV? Answer: The AWV has been designed as an annual overview of the patient’s health status, including elements of physical and mental health and general safety. It may be performed by clinical staff under physician or NPP supervision, and includes a review of known chronic conditions. In some situations, the patient’s chronic (or acute) condition(s) may require evaluation and management by the primary health care provider (physician or NPP). Documentation for these services may be included in one note or in two separate notes, based on the provider’s preference. Of note, the documentation must clearly delineate all necessary details of the AWV and all necessary elements of the E/M service relative to medical necessity and level of coding. Updated 2/20/2020

This NGS answer in a nutshell: sometimes yes, sometimes no.

If one of the patient’s conditions is not stable (as noted in the HPI, exam, assessment and treatment plan) , or, an acute problem is addressed, then do add a problem-oriented visit at the time of the wellness visit. Document the symptoms or the status of the condition in the HPI. If the HPI does not describe the conditions, don’t bill an E/M. The treatment plan should show either a change in treatment or a plan to monitor the condition.

Keep in mind the revised E/M guidelines for codes 99202–99215. Code selection for these office and other outpatient visits is based on time or medical decision making. History and exam are no longer key components in code selection. That makes it easier to meet the code requirements for a problem oriented visit. In my opinion, it is more defensible if the history describes either HPI symptoms for an acute problem or the status of chronic conditions.

And once again, if it is all copied from a prior note, don’t bill it!

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Last revised December 4, 2023 - Betsy Nicoletti Tags: Preventive and problem visits , primary care_preventive services

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Annual Wellness Visits: Maximizing Benefits for Patients and Practices

Free Live Webinar  

WED OCT 26 @12pm EST   30 minutes

 “An ounce of prevention is worth a pound of cure.” Medicare’s Annual Wellness Visits (AWV) aims to establish and incentivize a minimal annual touch point for all beneficiaries and their provider. Historically, practices experienced a major time burden facilitating these visits. With the right workflow and tools, practices can maximize benefits for patients and their practice.

In this free webinar, Robin Wisniewski, LPN, CMCN shares practical methods to streamline productivity and increase profitability. Health Prime has developed an easy-to-adopt, profitable AWV program and we are sharing our methods.  Robin will cover:

  • Benefits of AWVs
  • Streamlined AWV workflow
  • Methods to maximize AWV benefits – clinical and financial

SAVE YOUR SEAT

OCT 26th, 2022 at 12pm EST

annual wellness visit hpi

About the Speaker

Robin Wisniewski  is a care manager for the CCM and RPM Program with Health Prime. She has a nursing background in Internal Medicine, Family Medicine, Oncology, Hospice, Psychiatry, and Long Term Care. Robin previously completed a degree in business administration and is recognized as a nationally certified managed care nurse.

Health Prime International 174 Waterfront Street, Suite 330 National Harbor, MD 20745

Phone:  (301) 990-3995

Fax: (301) 990-3996

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Yearly "Wellness" visits

If you’ve had Medicare Part B (Medical Insurance) for longer than 12 months, you can get a yearly “Wellness” visit to develop or update your personalized plan to help prevent disease or disability, based on your current health and risk factors. The yearly “Wellness” visit isn’t a physical exam.

Your first yearly “Wellness” visit can’t take place within 12 months of your Part B enrollment or your “Welcome to Medicare” preventive visit. However, you don’t need to have had a “Welcome to Medicare” preventive visit to qualify for a yearly “Wellness” visit.

Your costs in Original Medicare

You pay nothing for this visit if your doctor or other health care provider accepts assignment .

The Part B deductible  doesn’t apply. 

However, you may have to pay coinsurance , and the Part B deductible may apply if your doctor or other health care provider performs additional tests or services during the same visit that Medicare doesn't cover under this preventive benefit.

If Medicare doesn't cover the additional tests or services (like a routine physical exam), you may have to pay the full amount.

Your doctor or other health care provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your doctor develop a personalized prevention plan to help you stay healthy and get the most out of your visit. Your visit may include:

  • Routine measurements (like height, weight, and blood pressure).
  • A review of your medical and family history.
  • A review of your current prescriptions.
  • Personalized health advice.
  • Advance care planning .

Your doctor or other health care provider will also perform a cognitive assessment to look for signs of dementia, including Alzheimer’s disease. Signs of cognitive impairment include trouble remembering, learning new things, concentrating, managing finances, and making decisions about your everyday life. If your doctor or other health care provider thinks you may have cognitive impairment, Medicare covers a separate visit to do a more thorough review of your cognitive function and check for conditions like dementia, depression, anxiety, or delirium and design a care plan.

If you have a current prescription for opioids, your doctor or other health care provider will review your potential risk factors for opioid use disorder, evaluate your severity of pain and current treatment plan, provide information on non-opioid treatment options, and may refer you to a specialist, if appropriate. Your doctor or other health care provider will also review your potential risk factors for substance use disorder, like alcohol and tobacco use , and refer you for treatment, if needed. 

Related resources

  • Preventive visits
  • Social determinants of health risk assessment

Is my test, item, or service covered?

Doctor Visits

Get Your Medicare Wellness Visit Every Year

Woman talking with health care provider.

Take Action

If you have Medicare, be sure to schedule a yearly wellness visit with your doctor or nurse. A yearly wellness visit is a great way to help you stay healthy.

What happens during a yearly wellness visit?

First, the doctor or nurse will ask you to fill out a questionnaire called a health risk assessment. Answering these questions will help you get the most from your yearly wellness visit.

During your visit, the doctor or nurse will:

  • Go over your health risk assessment with you
  • Measure your height and weight and check your blood pressure
  • Ask about your health history and conditions that run in your family 
  • Ask about other doctors you see and any medicines you take
  • Give advice to help you prevent disease, improve your health, and stay well
  • Look for any changes in your ability to think, learn, or remember
  • Ask about any risk factors for substance use disorder and talk with you about treatment options, if needed

If you take opioids to treat pain, the doctor or nurse may talk with you about your risk factors for opioid use disorder, review your treatment plan, and tell you about non-opioid treatment options. They may also refer you to a specialist. 

Finally, the doctor or nurse may give you a short, written plan to take home. This plan will include any screening tests and other preventive services that you’ll need in the next several years. Preventive services are health care services that keep you from getting sick. 

Learn more about yearly wellness visits .

Plan Your Visit

When can i go for a yearly wellness visit.

You can start getting Medicare wellness visits after you’ve had Medicare Part B for at least 12 months. Keep in mind you’ll need to wait 12 months in between Medicare wellness visits.

Do I need to have a “Welcome to Medicare” visit first?

You don’t need to have a “Welcome to Medicare” preventive visit before getting a yearly wellness visit.

If you choose to get the “Welcome to Medicare” visit during the first 12 months you have Medicare Part B, you’ll have to wait 12 months before you can get your first yearly wellness visit. 

Learn more about the “Welcome to Medicare” visit .

What about cost?

With Medicare Part B, you can get a wellness visit once a year at no cost to you. Check to make sure the doctor or nurse accepts Medicare when you schedule your appointment.

If you get any tests or services that aren’t included in the yearly wellness visit (like an extra blood test), you may have to pay some of those costs.

Who Can Get Medicare?

Medicare is a federal health insurance program. You may be able to get Medicare if you:

  • Are age 65 or older
  • Are under age 65 and have a disability
  • Have amyotrophic lateral sclerosis (ALS), also called Lou Gehrig's disease
  • Have permanent kidney failure (called end-stage renal disease)

You must be living in the United States legally for at least 5 years to qualify for Medicare.  Answer these questions to find out when you can sign up for Medicare .

Make an Appointment

Take these steps to help you get the most out of your Medicare yearly wellness visit.

Schedule your Medicare yearly wellness visit.

Call your doctor’s office and ask to schedule your Medicare yearly wellness visit. Make sure it’s been at least 12 months since your last wellness visit.

If you're looking for a new doctor,  check out these tips on choosing a doctor you can trust .  

To find a doctor who accepts Medicare:

  • Search for a doctor on the Medicare website
  • Call 1-800-MEDICARE (1-800-633-4227)
  • If you use a TTY, call Medicare at 1-877-486-2048

Gather important information.

Take any medical records or information you have to the appointment. Make sure you have important information like:

  • The name and phone number of a friend or relative to call if there’s an emergency
  • Dates and results of checkups and screening tests
  • A list of vaccines (shots) you’ve gotten and the dates you got them
  • Medicines you take (including over-the-counter medicines and vitamins), how much you take, and why you take them
  • Phone numbers and addresses of other places you go to for health care, including your pharmacy

Make a list of any important changes in your life or health.

Your doctor or nurse will want to know about any big changes since your last visit. For example, write down things like:

  • Losing your job
  • A death in the family
  • A serious illness or injury
  • A change in your living situation

Know your family health history.

Your family's health history is an important part of your personal health record.  Use this family health history tool  to keep track of conditions that run in your family. Take this information to your yearly wellness visit.

Ask Questions

Make a list of questions you want to ask the doctor..

This visit is a great time to ask the doctor or nurse any questions about:

  • A health condition
  • Changes in sleeping or eating habits
  • Pain or discomfort
  • Prescription medicines, over-the-counter medicines, or supplements

Some important questions include:

  • Do I need to get any vaccines to protect my health?
  • How can I get more physical activity?
  • Am I at a healthy weight?
  • Do I need to make any changes to my eating habits?

Use this question builder tool  to make a list of things to ask your doctor or nurse.

It can be helpful to write down the answers so you remember them later. You may also want to take a friend or relative with you for support — they can take notes, too.

What to Expect

Know what to expect at your visit..

The doctor or nurse will ask you questions about your health and safety, like:

  • Do you have stairs in your home?
  • What do you do to stay active?
  • Have you lost interest in doing things you usually enjoy?
  • Do you have a hard time hearing people on the phone?
  • What medicines, vitamins, or supplements do you take regularly?

The doctor or nurse will also do things like:

  • Measure your height and weight
  • Check your blood pressure
  • Ask about your medical and family history

Make a wellness plan with your doctor.

During the yearly wellness visit, the doctor or nurse may give you a short, written plan — like a checklist — to take home with you. This written plan will include a list of preventive services that you’ll need over the next 5 to 10 years.

Your plan may include:

  • Getting important screenings for cancer or other diseases
  • Making healthy changes, like getting more physical activity

Follow up after your visit.

During your yearly wellness visit, the doctor or nurse may recommend that you see a specialist or get certain tests. Try to schedule these follow-up appointments before you leave your wellness visit.

If that’s not possible, put a reminder note on your calendar to schedule your follow-up appointments.

Add any new health information to your personal health documents.

Make your next wellness visit easier by updating your medical information in the personal health documents you keep at home. Write down any vaccines you got and the results of any screening tests.

Medicare offers an online tool called  MyMedicare  to help you track your personal health information and Medicare claims. If you have your Medicare number, you can  sign up for your MyMedicare account now .

Healthy Habits

Take care of yourself all year long..

After your visit, follow the plan you made with your doctor or nurse to stay healthy. Your plan may include:

  • Getting important screenings
  • Getting vaccines for older adults
  • Keeping your heart healthy
  • Preventing type 2 diabetes
  • Lowering your risk of falling

Your plan could also include:

  • Getting active
  • Eating healthy
  • Quitting smoking
  • Watching your weight

Content last updated February 9, 2023

Reviewer Information

This information on Medicare wellness visits was adapted from materials from the Centers for Medicare and Medicaid Services

Reviewed by: Rachel Katonak Centers for Medicare and Medicaid Services Division of Policy and Evidence Review Coverage and Analysis Group

November 2022

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Initial Preventive Physical Examination (IPPE)

As part of the Affordable Care Act, Medicare provides coverage for an IPPE for patients who have been enrolled in Medicare for less than one year. It is a one-time service, intended to help provide an introduction to insurance coverage, benefits, and give appropriate screening for disease detection and preventive promotion of health. The IPPE must be performed within the first 12 months after the effective date of the beneficiary's Medicare Part B coverage.

An IPPE includes the following seven components:

  • A review of the beneficiary's medical and social history
  • Review of the beneficiary's potential risk factors for mood disorders
  • Review of the beneficiary's functional ability and level of safety
  • An examination
  • End-of-life planning
  • Education, counseling, and referral based on the previous five components
  • Education, counseling, and referral for other preventive services

Annual Wellness Visit (AWV)

As part of the Affordable Care Act, Medicare provides coverage for an AWV for patients who are enrolled in Medicare. This service may be covered as often as once per year. There are two specific types of AWV: initial and subsequent. Required elements for the initial AWV include:

  • A self-reported health risk assessment
  • Establishment of the beneficiary's medical/family history
  • A health assessment within the office
  • Establishment of current providers and suppliers of service
  • Detection of any cognitive impairment that the beneficiary may have
  • Establishment of a written screening schedule for the beneficiary
  • Establishment of a list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended for the beneficiary
  • Furnishing of personalized health advice to the beneficiary, and a referral for further care, if appropriate

The subsequent AWV visit will be updating the patient's past history as established during the initial visit, as well as a new assessment to establish any needed additional treatment. This is a shorter established service. Required elements for subsequent AWVs include:

  • Update of the self-reported risk assessment
  • An update of the beneficiary's medical/family history
  • Update of the list of current providers and suppliers of service
  • Update of the written screening schedule for the beneficiary
  • Update of the list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended for the patient
  • Furnishing of personal health advice to the beneficiary, and a referral for further care, if appropriate

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Documentation Requirements for the Medicare Annual Wellness Visit

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by Lucy Lamboley

The documentation requirements for the Medicare annual wellness visit (AWV) serve multiple purposes. Most importantly, documentation is critical to maximizing the value of the Medicare AWV to patients. As AARP  notes , the Medicare AWV is "… designed to promote the use of preventive care, identify health risks, and plan for future healthcare needs." In addition, the Medicare AWV is an opportunity for patients to meet with providers who can also deliver or schedule preventive services, which we discuss in this blog post that shares HCPCS and CPT codes for billing the AWV and supplementary preventive services.

Meeting documentation requirements for the Medicare annual wellness visit is also critical for receiving reimbursement. If a provider fails to complete documentation requirements, it increases the likelihood of the denial of a claim, which will delay payment and grow the associated costs (e.g., staff time, reprinting of documentation) of billing and getting paid for the service.

Finally, completing documentation requirements for the Medicare annual wellness visit is essential for avoiding non-compliance penalties from audits. The Centers for Medicare & Medicaid Services notes that insufficient or missing documentation is one of the top two contributors to a majority of Medicare fee-for-service improper payments, while the majority of Medicaid and CHIP improper payments are tied to insufficient or missing documentation. Penalties  associated with documentation issues can result in revenue loss for a practice, exclusion from Medicare, or even criminal liability in egregious cases.

In fact, one survey suggests that upwards of about 85% of Medicare annual wellness visits may fail to meet compliance requirements set forth by CMS. 

To help ensure your patients receive the best Medicare annual wellness visit experience possible and your organization receives full, proper reimbursement — and avoids giving any of it back — for the provision of the service, let's review documentation requirements for the Medicare annual wellness visit. We'll break these out by the initial AWV and subsequent AWVs.

Note: If you're unsure who is and is not eligible for the AWV, we recommend downloading this AWV eligibility quick guide .

Documentation Requirements for Initial Medicare Annual Wellness Visit

The documentation requirements for the initial Medicare annual wellness visit are as follows

Health risk assessment. 

Medical and family history., current providers and suppliers., routine measurements., cognitive function., potential risk factors for depression., functional ability and safety., written screening schedule..

"Within the regulations is the expectation that patients will be 'furnished' with the personalized prevention plan and advice. While furnished is not specifically defined, it has been interpreted to mean either a physical copy of the PPPS handed to the patient upon completion of the AWV or a copy placed into a patient's active health portal account."

Risk factors and conditions.

Health advice and referrals., upon request: advance care planning services (acp), documentation requirements for subsequent medicare annual wellness visits.

The documentation requirements for subsequent annual wellness visits after a  beneficiary's first AWV  are as follows:

  • Update the HRA
  • Update the beneficiary's medical and family history
  • Update the list of current healthcare providers and suppliers
  • Document the routine, essential measurements
  • Assess cognitive function
  • Discuss depression and risk factors
  • Update the written screening schedule
  • Update risk factors and conditions for which interventions are recommended/underway
  • Update the prevention plan of service, including personalized health advice and referrals to health education and/or preventive counseling services or programs, as appropriate
  • Review/discuss advance care planning services, at the patient's discretion

Properly Completing Documentation Requirements for the Medicare Annual Wellness Visit

While it's important to understand all the Medicare AWV documentation requirements, keeping track of all these requirements and ensuring they are completed properly is challenging for any organization. That's why a growing number of providers are turning to solutions like Prevounce's Medicare annual wellness visit software to provide prompts that better ensure completion and proper documentation of all required components. Some solutions, like Prevounce's, can also generate the comprehensive documentation necessary if an organization undergoes a chart check or audit. To learn more about the powerful Prevounce AWV platform and see it in action, schedule a demo today .

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The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical. Also, this service is similar to but separate from the one-time Welcome to Medicare preventive visit .

Eligibility

Medicare Part B covers the Annual Wellness Visit if:

  • You have had Part B for over 12 months
  • And, you have not received an AWV in the past 12 months

Additionally, you cannot receive your AWV within the same year as your Welcome to Medicare preventive visit.

Covered services

During your first Annual Wellness Visit, your PCP will develop your personalized prevention plan. Your PCP may also:

  • Check your height, weight, blood pressure, and other routine measurements
  • This may include a questionnaire that you complete before or during the visit. The questionnaire asks about your health status, injury risks, behavioral risks, and urgent health needs.
  • This includes screening for hearing impairments and your risk of falling.
  • Your doctor must also assess your ability to perform activities of daily living (such as bathing and dressing), and your level of safety at home.
  • Learn about your medical and family history
  • Medications include prescription medications, as well as vitamins and supplements you may take
  • Your PCP should keep in mind your health status, screening history, and eligibility for age-appropriate, Medicare-covered preventive services
  • Medicare does not require that doctors use a test to screen you. Instead, doctors are asked to rely on their observations and/or on reports by you and others.
  • Screen for depression
  • Health education and preventive counseling may relate to weight loss, physical activity, smoking cessation, fall prevention, nutrition, and more.

AWVs after your first visit may be different. At subsequent AWVs, your doctor should:

  • Check your weight and blood pressure
  • Update the health risk assessment you completed
  • Update your medical and family history
  • Update your list of current medical providers and suppliers
  • Update your written screening schedule
  • Screen for cognitive issues
  • Provide health advice and referrals to health education and/or preventive counseling services

If you qualify, Original Medicare covers the Annual Wellness Visit at 100% of the Medicare-approved amount when you receive the service from a participating provider . This means you pay nothing (no deductible or coinsurance ). Medicare Advantage Plans are required to cover AWVs without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s eligibility requirements for the service.

During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit.

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Common questions about Medicare annual wellness visits

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If you are a Medicare recipient, you can take advantage of annual wellness visits. These visits are a preventive health benefit available after having Medicare Part B coverage for at least one year. All Medicare Advantage Plans are required to offer annual wellness visits for their members. A nurse or nurse practitioner reviews your health status and helps you plan for health and wellness needs.

In most cases, the annual wellness visit will be followed by a separate medical visit  with your primary care professional to close any health care gaps and address any problems identified during the visit.

Here are answers to common questions about annual wellness visits.

Why are annual wellness visits important.

The annual wellness visit allows you to review your health history and identify any current or potential health risks with a health care professional. The visit enables the nurse to focus on prevention and wellness while making sure you are current on recommended immunizations and health screenings like colonoscopies or mammograms. It also allows your primary care professional more time to focus on your medical concerns and needs at a separate physical exam.

Do I need to be 65 or older to have an annual wellness visit?

You do not need to be 65 or older to qualify for an annual wellness visit as long as you've been on Medicare Part B for at least one year.

How is an annual wellness visit scheduled?

If you are due for an annual wellness visit, you may be prompted to self-schedule the visit in the patient portal . You also may call your care team and ask to be scheduled.

If your visit is with a nurse or nurse practitioner, it's recommended to schedule this visit before the visit with your primary care professional. This allows your primary care professional the chance to address any concerns mentioned during your annual wellness visit.

How can I prepare for my annual wellness visit?

You may be asked to complete some questionnaires before arriving for your appointment, which will be sent to your patient portal account. If you cannot access the questionnaires before the appointment, plan to arrive at your appointment early to complete them.

It's helpful to come prepared to your visit with this information:

  • All medications, vitamins and supplements you take, including how much and how often you take them
  • Additional medical records, including immunization records
  • Dates of your most recent preventive services, like a colonoscopy or mammogram, if completed by another health care facility
  • Family health history, with as much detail as possible
  • List of medical providers and suppliers who provide you care, equipment or services

What can you expect during an annual wellness visit?

During the visit, you'll meet with a nurse or nurse practitioner to:.

  • Evaluate your fall risk
  • Measure your height, weight and blood pressure
  • Offer referrals to other health education or preventive services
  • Provide information related to voluntary advance care planning
  • Screen for cognitive impairments like dementia
  • Screen for depression
  • Update your medical and family history

What is the cost of an annual wellness visit?

Medicare offers the visit at no cost for people who have Medicare Part B coverage for at least one year before the visit. If you are referred for other tests or services, they will be billed to your insurance. If you have a separate visit with your primary care professional following your annual wellness visit, you or your insurance carrier will be responsible for the cost of that visit.

Robert Stroebel, M.D. , is a Community Internal Medicine, Geriatric and Palliative Care physician at Mayo Clinic Primary Care in Rochester and Kasson, Minnesota.

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JOEL J. HEIDELBAUGH, MD

Am Fam Physician. 2018;98(12):729-737

Patient information : See related handout on adult men's health .

Author disclosure: No relevant financial affiliations.

The adult well-male examination should provide evidence-based guidance toward the promotion of optimal health and well-being. The medical history should focus on tobacco and alcohol use, risk of human immunodeficiency virus and other sexually transmitted infections, and diet and exercise habits. The physical examination should include blood pressure screening, and height and weight measurements to calculate body mass index. Lipid screening is performed in men 40 to 75 years of age; there is insufficient evidence for screening younger men. One-time screening ultrasonography for detection of abdominal aortic aneurysm is recommended in men 65 to 75 years of age who have ever smoked. Screening for prostate cancer using prostate-specific antigen testing in men 55 to 69 years of age should be individualized using shared decision making. Screening for colorectal cancer should begin at 50 years of age for average-risk men and continue until at least 75 years of age. Screening options include fecal immunochemical testing, colonoscopy, or computed tomography colonography. Lung cancer screening using low-dose computed tomography is recommended in men 55 to 80 years of age who have at least a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. Immunizations should be updated according to guidelines from the Advisory Committee on Immunization Practices.

The goals of the adult well-male examination are to provide evidence-based guidance toward the promotion of optimal health and well-being, to screen for and potentially prevent premature morbidity and mortality from chronic diseases, and to provide age-appropriate cancer screening and immunizations. Most primary care guidelines come from the U.S. Preventive Services Task Force (USPSTF) and have been adopted by the American Academy of Family Physicians (AAFP). 1 , 2 Some subspecialty guidelines offer additional guidance but may have conflicting recommendations. Currently, there is no accepted guideline for frequency of adult well-male examinations, although many private health insurance plans and Medicare recommend annual examinations.

WHAT IS NEW ON THIS TOPIC

The life expectancy of U.S. men in 2015 was 76.3 years, a slight decrease from previous averages and five years lower than that of women.

The U.S. Preventive Services Task Force found insufficient evidence to recommend for or against lipid screening in any risk group younger than 40 years.

In 2007, men 15 to 65 years of age were significantly less likely than women to seek preventive care services from a primary care physician (15% vs. 44% of total visits, respectively). 3 In 2000, one in three men reported not having a primary care physician, compared with one in five women. 4 No data are available on the impact of the Patient Protection and Affordable Care Act. The life expectancy of U.S. men in 2015 was 76.3 years, a slight decrease from previous averages and five years lower than that of women. 5 Table 1 includes Centers for Disease Control and Prevention statistics related to men’s health and well-being. 6

For the evaluation of men, the patient history should be comprised of medical and surgical histories, current medications, and allergies. Family history relevant to the risk of chronic diseases and cancer should also be included. Social history should focus on lifestyle risks that contribute to premature morbidity and mortality, including substance use, risk of human immunodeficiency virus and other sexually transmitted infections (STIs), and diet and exercise habits. Evaluation of men with Medicare should also include gait stability, their ability to achieve activities of daily living, and depression screening.

Screening for Lifestyle and Mental Health Risks

Table 2 summarizes screening guidelines for lifestyle and mental health risks in men. 7 – 21

TOBACCO AND SUBSTANCE USE

Men should be asked about tobacco and alcohol use at every visit. 7 , 8 The USPSTF found insufficient evidence to recommend for or against screening for illicit drug use 9 ; however, the National Institute on Drug Abuse recommends screening for nonmedical prescription drug use and other illicit drug use. 10 Clinicians can use recommended counseling approaches such as the five A’s (ask, advise, assess, assist, and arrange), the CAGE questionnaire, or motivational interviewing. 8 , 22

SEXUALLY TRANSMITTED INFECTIONS

Men with risk factors, including men with multiple sex partners, men who engage in unprotected sex, and men who have sex with men, should be screened for STIs. 11 , 12 , 23 There is good evidence of increased yield from routine screening for human immunodeficiency virus infection in persons who report no individual risk factors but are seen in high-risk or high-prevalence clinical settings, including STI clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics that have a high prevalence of STIs. However, all men should be offered screening. 13

One study concluded that counseling patients about the use of condoms is likely to benefit some patients at STI clinics and minimize the risk of infection transmission, although it is unlikely to benefit men who have sex with men. 24 The cost-effectiveness of implementing behavioral counseling in STI programs is unclear, but feasibility would be improved if behavioral counseling were implemented in the context of other prevention efforts.

Men should be screened for depression using the two-item Patient Health Questionnaire (PHQ; http://www.commonwealthfund.org/usr_doc/PHQ2.pdf ). If results of the PHQ-2 are positive, the patient should be further evaluated using the PHQ-9 ( https://www.phqscreeners.com/sites/g/files/g10049256/f/201412/PHQ-9_English.pdf ). 17

Screening for Chronic Conditions

Table 3 summarizes screening guidelines for chronic conditions in men. 18 , 25 – 40

CARDIOVASCULAR RISK

Components of the adult well-male examination include blood pressure screening and height and weight measurements to calculate body mass index (BMI). 18 , 25

Hypertension . Men should be screened for high blood pressure. 25 When treatment decisions are being made, blood pressure should be considered with global risk of cardiovascular disease (CVD); smoking status; presence of diabetes mellitus, dyslipidemia, or obesity; physical activity level; age; and sex. 25 Hypertension (defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher by the Eighth Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC-8]) can be diagnosed after two or more elevated readings are obtained on at least two visits over a period of one to several weeks. 28 Recent guidelines recommend a cutoff for stage 1 hypertension of 130 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic 41 ; however, the AAFP continues to support the cutoff recommended by the JNC-8. 26 , 42

Evidence supports ambulatory blood pressure monitoring as the reference standard for confirming elevated office blood pressure measurements to avoid misdiagnosis and overtreatment of persons with isolated clinic hypertension (white coat hypertension). 29 The ASCVD (Atherosclerotic Cardiovascular Disease) Risk Estimator (available at http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/ ) can be used to determine the 10-year risk of cardiovascular events or stroke in men 40 to 79 years of age.

Obesity . Height and weight measurements should be obtained at every visit to calculate BMI. 18 An abdominal (waist) circumference greater than 40 inches is associated with an increased risk of type 2 diabetes, dyslipidemia, hypertension, and CVD in men with a BMI of 25 to 35 kg per m 2 . 43 In persons with a BMI of 35 kg per m 2 or greater, determination of waist circumference has limited additional value in the prediction of CVD risk. 43 In Asian and black men, waist circumference and other measures such as waist-to-height ratio may be better indicators of CVD risk than BMI because BMI does not adequately account for differences in visceral fat distribution. 43

Diabetes . Among men 20 years and older, more than 15 million have diabetes and approximately 44.5 million have prediabetes. 44 Diabetes is considered a CVD risk equivalent because diabetes-related comorbidity with other risk factors leads to a higher risk of CVD within 10 years. 31 The American Diabetes Association defines diabetes as an A1C level of 6.5% or higher; fasting plasma glucose concentration of 126 mg per dL (7.0 mmol per L) or greater; plasma glucose concentration of 200 mg per dL (11.1 mmol per L) or greater two hours after a 75-g oral glucose load; and a random plasma glucose concentration of 200 mg per dL or greater in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis (e.g., polyuria, polydipsia, polyphagia). 32

Dyslipidemia . The USPSTF recommends lipid screening in men 40 to 75 years of age; a risk calculator is then used to determine the need for treatment. 33 The optimal interval for screening is uncertain. 33 Notably, the USPSTF found insufficient evidence to recommend for or against screening in any risk group younger than 40 years. 33

Risk factors for CVD include elevated low-density lipoprotein cholesterol, history of CVD or noncoronary atherosclerosis, diabetes, smoking, hypertension, obesity, and family history of CVD before 50 years of age in male relatives or before 60 years of age in female relatives. 33 , 34

Fasting lipoprotein profile is the preferred screening test for dyslipidemia. 33 , 34 For nonfasting samples, total cholesterol and high-density lipoprotein cholesterol measurements are recommended and are sufficient for calculating 10-year cardiovascular risk using most calculators. 45 , 46

Abdominal Aortic Aneurysm . The USPSTF recommends one-time screening ultrasonography for detection of abdominal aortic aneurysm in men 65 to 75 years of age who have ever smoked. 35 Randomized trials show that the benefits of screening and surgical repair in this high-risk group outweigh potential harms. 35 The pooled prevalence of abdominal aortic aneurysm is 4.4%. 47 The mortality rate after dissection and rupture approaches 80% for men who reach the hospital and 50% for men who undergo emergent surgical repair. 48 Smoking is the risk factor most strongly associated with abdominal aortic aneurysm (odds ratio = 5.07) and accounts for 75% of all aneurysms 4 cm or greater. 49 Other risk factors include hypertension, dyslipidemia, family history, and atherosclerosis. A meta-analysis determined that a well-functioning screening program would reduce abdominal aortic aneurysm–related mortality by at least 45%; the number needed to screen to prevent one rupture is 238. 50

OSTEOPOROSIS

The USPSTF found insufficient evidence to recommend for or against screening men for osteoporosis, given that the relative benefits and harms of therapy for osteoporosis in men have not been determined. 36 Although evidence for screening is lacking, men most likely to benefit from screening would have a 10-year risk of osteoporotic fracture equal to or greater than that of a 65-year-old white woman with no additional risk factors. 36 For men, major risk factors include increasing age, white race, and family history. The National Osteoporosis Foundation recommends bone mineral density testing for all men 70 years or older and men 50 to 69 years of age with risk factors (e.g., frailty, low BMI). 37 The USPSTF found insufficient evidence to recommend for or against calcium and vitamin D supplementation to prevent fractures. 51

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

The USPSTF recommends against screening adults for chronic obstructive pulmonary disease (COPD) using spirometry. 38 Men with COPD, including those with mild or moderate illness, benefit from smoking cessation and annual influenza vaccination. Moderate evidence suggests that influenza vaccination reduces COPD exacerbations. 38

HEPATITIS C

Screening for hepatitis C should be offered to men at high risk of infection. Adults born between 1945 and 1965 should be offered one-time screening. 39

Cancer Screening

Table 4 summarizes screening guidelines for cancer in men. 52 – 61

TESTICULAR CANCER

The USPSTF recommends against screening asymptomatic men for testicular cancer. Because the incidence of testicular cancer is very low and treatment is often effective even in advanced stages, the benefits of earlier detection are minimal and likely outweighed by the harms of false-positive results and unnecessary workup for benign conditions. 52

SKIN CANCER

The USPSTF concludes that there is insufficient evidence to assess the benefits vs. harms of a whole-body skin examination performed by a primary care clinician for the early detection of skin cancer in men. It concludes that there is also insufficient evidence to assess the benefits vs. harms of counseling patients about performing self-examinations. 53 , 54

PROSTATE CANCER

Screening for prostate cancer in primary care is controversial because it is widely believed that screening has resulted in overdiagnosis and overtreatment of clinically insignificant cancers. An editorial on prostate cancer screening was published in American Family Physician (available at https://www.aafp.org/afp/2018/1015/p478.html ).

Previous USPSTF recommendations argued against screening for prostate cancer with prostate-specific antigen testing because of possible harms, based on data from the European Randomized Study of Screening for Prostate Cancer and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. 62 Current USPSTF and AAFP guidelines align with American Urological Association guidelines in recommending a discussion of benefits vs. risks of screening for men 55 to 69 years of age and using a shared decision-making approach; screening decisions should be individualized based on risk factors (i.e., family history, black race) and take into account the patient’s values and preferences. 55 , 56 , 63 The USPSTF and AAFP recommend against prostate-specific antigen screening for prostate cancer in men 70 years and older. 55 , 56

Although not recommended by the USPSTF, expert opinion from the American Urological Association and data from an uncontrolled trial suggest that prostate cancer screening should combine the digital rectal examination and prostate-specific antigen test, which improves detection compared with either test alone (positive predictive value = 18% and 45%, respectively). 56 , 64

COLORECTAL CANCER

Screening for colorectal cancer should begin at 50 years of age for average-risk men and continue until at least 75 years of age. 57 Colonoscopy is increasingly becoming the test of choice for colorectal cancer screening in primary care, yet there are no randomized controlled trials comparing colonoscopy, flexible sigmoidoscopy, and fecal occult blood testing (FOBT) with a definable outcome of cancer-specific or all-cause mortality. 57 , 65 , 66 Fecal immunochemical testing has greater sensitivity and specificity compared with guaiac-based FOBT. 67 Fecal DNA testing has not proved more accurate than FOBT or fecal immunochemical testing and has more false-positive results than FOBT (16% vs. 5%). 68 Computed tomography colonography may result in harms from low-dose ionizing radiation exposure or identification of extracolonic findings. 69

LUNG CANCER

Lung cancer is the third most common cancer and the leading cause of preventable cancer-related death in the United States. 70 Smoking is the most important risk factor for lung cancer, accounting for approximately 85% of cases. 71 The USPSTF recommends annual screening for lung cancer with low-dose computed tomography in adults 55 to 80 years of age who have at least a 30-pack-year smoking history and currently smoke or have quit within the past 15 years, 59 , 72 whereas the AAFP concludes that the evidence is insufficient to recommend for or against screening. 60 Physicians should be aware of the high rate of false-positives with low-dose computed tomography screening; more than one-half of patients require additional testing and tracking, of which only 1.5% receive a lung cancer diagnosis. 73 Screening should be discontinued once a patient has not smoked for 15 years or if a patient develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. 59

Immunizations

The Advisory Committee on Immunization Practices (ACIP) strongly encourages annual influenza vaccination for all adults, with the high-dose preparation recommended for those older than 65 years. ACIP recommends a single tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination, regardless of when the last tetanus and diphtheria toxoids (Td) booster was given. 74

A vaccine series does not need to be restarted, even if a long period has passed between doses, although immunity may need to be verified via serologic testing. 74 Full ACIP vaccine recommendations are available at https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html .

This article updates a previous article on this topic by Heidelbaugh and Tortorello . 75

Data Sources : I performed a bibliographic search of select men’s health topics highlighting USPSTF guidelines, the Cochrane Database of Systematic Reviews, Essential Evidence Plus, the American Urological Association, the Agency for Healthcare Research and Quality, DynaMed, and the National Guideline Clearinghouse database. I searched Medline using the terms men’s health, guidelines, evidence-based, hypertension, hyperlipidemia, obesity, diabetes mellitus, abdominal aortic aneurysm, osteoporosis, prostate cancer, colorectal cancer, lung cancer, testicular cancer, skin cancer, sexually transmitted diseases/infections, and immunizations. Original research studies cited within these guidelines were reviewed. Search dates: September through November 2017.

USPSTF. Published recommendations. http://www.uspreventiveservicestaskforce.org/uspstopics.htm . Accessed September 14, 2017.

AAFP. Clinical recommendations. https://www.aafp.org/online/en/home/clinical/exam.html . Accessed September 14, 2017.

Hsiao CJ, Cherry DK, Beatty PC, Rechtsteiner EA. National ambulatory medical care survey. Natl Health Stat Report. 2010(27):1-32.

Sandman D, Simantov E, An C. Out of touch: American men and the health care system. March 2000. http://www.usrf.org/breakingnews/Men_out_of_touch.pdf . Accessed December 2, 2017.

CDC. Health, United States, 2016. https://www.cdc.gov/nchs/data/hus/hus16.pdf#015 . Accessed August 17, 2018.

CDC. Fast stats. Men's health. https://www.cdc.gov/nchs/fastats/mens-health.htm . Accessed September 15, 2017.

USPSTF. Tobacco smoking cessation in adults, including pregnant women: behavioral and pharmacotherapy interventions. September 2015. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1 . Accessed September 14, 2017.

USPSTF. Alcohol misuse. May 2013. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/alcohol-misuse-screening-and-behavioral-counseling-interventions-in-primary-care . Accessed September 14, 2017.

USPSTF. Drug use, illicit. January 2008. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/drug-use-illicit-screening . Accessed September 14, 2017.

National Institute on Drug Abuse. Resource guide: screening for drug use in general medical settings. https://www.drugabuse.gov/publications/resource-guide-screening-drug-use-in-general-medical-settings/introduction . Accessed August 17, 2018.

USPSTF. Sexually transmitted infections: behavioral counseling. September 2014. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/sexually-transmitted-infections-behavioral-counseling1 . Accessed September 14, 2017.

USPSTF. Syphilis infection in nonpregnant adults and adolescents: screening. June 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/syphilis-infection-in-nonpregnant-adults-and-adolescents . Accessed April 13, 2018.

USPSTF. Human immunodeficiency virus (HIV) infection: screening. April 2013. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/human-immunodeficiency-virus-hiv-infection-screening . Accessed September 14, 2017.

AAFP. HIV screening, adolescents and adults. https://www.aafp.org/patient-care/clinical-recommendations/all/hiv-screening.html . Accessed August 17, 2018.

Branson BM, Handsfield HH, Lampe MA, et al.; CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17.

DiNenno EA, Prejean J, Irwin K, et al. Recommendations for HIV screening of gay, bisexual, and other men who have sex with men - United States, 2017. MMWR Morb Mortal Wkly Rep. 2017;66(31):830-832.

USPSTF. Depression in adults: screening. January 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-adults-screening1 . Accessed September 14, 2017.

USPSTF. Weight loss to prevent obesity-related morbidity and mortality in adults: behavioral interventions. September 2018. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obesity-in-adults-interventions1 . Accessed October 17, 2018.

USPSTF. Healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors. August 2014. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/healthy-diet-and-physical-activity-counseling-adults-with-high-risk-of-cvd . Accessed September 27, 2018.

U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary guidelines for Americans. 2015–2020. Eighth edition. December 2015. https://health.gov/dietaryguidelines/2015/guidelines/ . Accessed November 4, 2017.

U.S. Department of Health and Human Services. Physical activity guidelines. Adults. https://health.gov/paguidelines/guidelines/adults.aspx . Accessed November 4, 2017.

Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252(14):1905-1907.

CDC. STD and HIV screening recommendations. https://www.cdc.gov/std/prevention/screeningreccs.htm . Accessed September 27, 2018.

Brookmeyer KA, Hogben M, Kinsey J. The role of behavioral counseling in sexually transmitted disease prevention program settings. Sex Transm Dis. 2016;43(2 suppl 1):S102-S112.

USPSTF. High blood pressure in adults: screening. October 2015. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/high-blood-pressure-in-adults-screening . Accessed September 14, 2017.

AAFP. Clinical practice guideline. Hypertension. https://www.aafp.org/patient-care/clinical-recommendations/all/highbloodpressure.html . Accessed August 17, 2018.

Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.

James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) [published correction appears in JAMA . 2014;311(17):1809]. JAMA. 2014;311(5):507-520.

Piper MA, Evans CV, Burda BU, et al. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2015;162(3):192-204.

Brauer P, Connor Gorber S, Shaw E, et al.; Canadian Task Force on Preventive Health Care. Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care. CMAJ. 2015;187(3):184-195.

USPSTF. Abnormal blood glucose and type 2 diabetes mellitus: screening. October 2015. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes . Accessed April 13, 2018.

American Diabetes Association. Classification and diagnosis of diabetes: standards of medical care in diabetes–2018. Diabetes Care. 2018;41(suppl 1):S13-S27.

USPSTF. Statin use for the primary prevention of cardiovascular disease in adults: preventive medication. November 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/statin-use-in-adults-preventive-medication1 . Accessed August 17, 2018.

National Heart, Lung, and Blood Institute. National Cholesterol Education Program. Detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). May 2001. https://www.nhlbi.nih.gov/files/docs/guidelines/atp3xsum.pdf . Accessed August 17, 2018.

USPSTF. Abdominal aortic aneurysm: screening. June 2014. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/abdominal-aortic-aneurysm-screening . Accessed September 14, 2017.

USPSTF. Osteoporosis to prevent fractures: screening. June 2018. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/osteoporosis-screening1 . Accessed August 8, 2018.

National Osteoporosis Foundation. Clinician's guide to prevention and treatment of osteoporosis. https://my.nof.org/bone-source/education/clinicians-guide-to-the-prevention-and-treatment-of-osteoporosis . Accessed August 17, 2018.

USPSTF. Chronic obstructive pulmonary disease: screening. April 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chronic-obstructive-pulmonary-disease-screening . Accessed September 14, 2017.

USPSTF. Hepatitis C: screening. June 2013. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/hepatitis-c-screening . Accessed April 13, 2018.

Kanwal F, Bacon BR, Beste LA, et al. Hepatitis C virus infection care pathway—a report from the American Gastroenterological Association Institute HCV Care Pathway Work Group. Gastroenterology. 2017;152(6):1588-1598.

Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults [published correction appears in Hypertension . 2018;71(6):e140-e144]. Hypertension. 2018;71(6):e13-e115.

LeFevre M. ACC/AHA hypertension guideline: what is new? What do we do?. Am Fam Physician. 2018;97(6):372-373.

National Heart, Lung, and Blood Institute. Guidelines on overweight and obesity: electronic textbook. https://www.nhlbi.nih.gov/health-pro/guidelines/current/obesity-guidelines/e_textbook/txgd/4142.htm . Accessed November 7, 2018.

CDC. National diabetes statistics report, 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf . Accessed November 19, 2017.

Farukhi Z, Mora S. Re-assessing the role of non-fasting lipids; a change in sperspective. Ann Transl Med. 2016;4(21):431.

Driver SL, Martin SS, Gluckman TJ, et al. Fasting or nonfasting lipid measurements: it depends on the question. J Am Coll Cardiol. 2016;67(10):1227-1234.

Li X, Zhao G, Zhang J, et al. Prevalence and trends of the abdominal aortic aneurysms epidemic in general population—a meta-analysis. PLoS One. 2013;8(12):e81260.

Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007(2):CD002945.

Lederle FA, Johnson GR, Wilson SE, et al.; Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. The aneurysm detection and management study screening program: validation cohort and final results. Arch Intern Med. 2000;160(10):1425-1430.

Takagi H, Goto SN, Matsui M, et al. A further meta-analysis of population-based screening for abdominal aortic aneurysm. J Vasc Surg. 2010;52(4):1103-1108.

USPSTF. Vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults. April 2018. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/vitamin-d-calcium-or-combined-supplementation-for-the-primary-prevention-of-fractures-in-adults-preventive-medication . Accessed August 17, 2018.

USPSTF. Testicular cancer: screening. April 2011. http://www.uspreventiveservicestaskforce.org/uspstf/uspstest.htm . Accessed September 14, 2017.

USPSTF. Skin cancer: screening. July 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancer-screening2 . Accessed August 8, 2018.

USPSTF. Skin cancer prevention: behavioral counseling. March 2018. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancer-counseling2 . Accessed August 17, 2018.

USPSTF. Prostate cancer: screening. May 2018. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening1 . Accessed August 8, 2018.

American Urological Association. Early detection of prostate cancer. http://www.auanet.org/guidelines/prostate-cancer-early-detection-(2013-reviewed-for-currency-2018) . Accessed September 14, 2017.

USPSTF. Colorectal cancer: screening. June 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-cancer-screening2 . Accessed September 14, 2017.

Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [published correction appears in Am J Gastroenterol . 2009;104(6):1613]. Am J Gastroenterol. 2009;104(3):739-750.

USPSTF. Lung cancer: screening. December 2013. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening . Accessed September 14, 2017.

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  1. The Importance Of Annual Wellness Visits

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  2. Combining a Wellness Visit With a Problem-Oriented Visit: a Coding

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  3. Annual Wellness Visit Template

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  4. How Do You Bill The Medicare Annual Wellness Visit

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  5. Medicare Annual Wellness Visits

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  6. What Medicare Patients Should Know About the Annual Wellness Visit

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COMMENTS

  1. Combining a Wellness Visit With a Problem-Oriented Visit: a ...

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    First, the doctor or nurse will ask you to fill out a questionnaire called a health risk assessment. Answering these questions will help you get the most from your yearly wellness visit. During your visit, the doctor or nurse will: Go over your health risk assessment with you. Measure your height and weight and check your blood pressure.

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    January 14, 2021. Annual Wellness Visits (AWVs) and Initial Preventive Physical Examinations (IPPEs) versus "Routine Examinations" Medicare may cover two specialized physical examination services for eligible beneficiaries: the Initial Preventive Physical Examination (IPPE) and an Annual Wellness Visit (AWV).

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    Vital sign records, weight sheets, care plans, treatment records. Estimation of intellectual functioning, memory functioning, and orientation. Record of mental status. Mini mental status exam (MMSE) or similar test score. Cognitive function. Written screening test (s) schedule.

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