Annual Wellness Visits (AWV) for Medicare beneficiaries can add measurable value to benefit patient health outcomes, quality performance, and service revenue. However, it’s critical to optimize physician and staff time with a reliable, standards-based, and streamlined workflow.
To help, we’ve created a comprehensive AWV workflow and checklist that matches Medicare requirements. Providers can use this independently to create an AWV strategy or use ThoroughCare, a care management software platform, to put this plan into action.
AWV case demonstrates best practices that deliver ROI
It’s important to envision what’s possible for implementing or expanding Medicare Annual Wellness Visits.
The Department of Family and Community Medicine at Eastern Virginia Medical School provides a real-world example. The department was concerned by its low AWV completion rates, well below the national average of 25%.
Previous physician staff member with the Eastern Virginia Medical School, Daniel Bluestein, MD, detailed actions taken by the organization in a webinar with the American Academy of Family Physicians.
Figure 1: Best practices Dr. Bluestein’s team used to recruit patients for AWVs. Source.
By implementing various best practices through a proactive AWV workflow and team-based approach, they achieved a 300% increase in completed AWVs in a year. Additionally, they generated more than $58,000 in AWV revenue, not counting AWV add-on services, care management enrollments, or subsequent AWVs they garnered. Subsequent AWVs alone were expected to generate $17,500 in annual revenue.
Dr. Bluestein’s team was able to triple their AWV completion rate because they adopted the best practices shown in Figure 1. They utilized a care manager to carry out most of the AWV, engaging a physician only when escalation was clinically necessary.
Their program uncovered vital insights, including:
- 90% of patients received an AWV at the recommendation of their doctor
- 61% of patients had never heard of an AWV before, nor its benefits
- 14% of physicians had previously been deterred by the billing and physician time complexities
This approach to Medicare Annual Wellness Visits helped close care gaps, improve quality outcomes, and generate nearly $60,000 in revenue through existing staff resources. It also opened the door to enrolling patients in other care management programs or services, such as:
- Chronic Care Management
- Transitional Care Management
- Advance Care Planning
- Health-related social needs screenings
Address four areas to maximize Annual Wellness Visits
Focusing on the following four components supports a proactive, team-based AWV workflow:
- Identifying eligible patients
- Delivering required activities
- Creating accurate and compliant billing
- Using the AWV as an enrollment opportunity for medically necessary care management programs
1. Who and when? Identifying the right patient for one of three Medicare AWVs
As shown in Figure 2, there are three types of Annual Wellness Visits. Based on Medicare eligibility criteria, beneficiaries have access to all three visits within specific time constraints.
Providers can use ThoroughCare’s AWV functionality to automatically identify eligible patients and offer the most appropriate type of wellness visit. Or, they can leverage their EHR to manually enroll patients based on the following criteria:
Figure 2: Three types of Medicare Annual Wellness Visits with beneficiary eligibility and timing.
2. What activities? Delivering the right wellness visit activities
It’s vital to understand what activities Medicare requires and the differences among the three types of AWVs.
In addition to timing, the main differences between an Initial Preventive Physical Exam, or “Welcome to Medicare” visit, and an AWV include:
- An IPPE features an initial assessment of the beneficiary’s health status and standards-based preventive health needs
- The AWV utilizes a Health Risk Assessment to develop a Personalized Prevention Plan based on the patient's health status and risk factors
While there is ample overlap, the subtle differences relate to reimbursement requirements. For example, the IPPE includes visual acuity and balance assessments as part of the limited exam, but the AWV office tests do not.
As shown in Figure 3, ThoroughCare, a care management software platform, provides a standardized, easy-to-follow workflow across all three types. If developing a manual workflow, this crosswalk can still be a helpful guide.
ThoroughCare's AWV workflow covers all key components of the assessment
Figure 3: Medicare Annual Wellness Visit crosswalk and workflow.
The Centers for Medicare & Medicaid Services (CMS) and professional associations offer additional resources to develop specific activities to fill the workflow:
- CMS: IPPE component list
- CMS: Initial and subsequent AWV component list
- American College of Physicians: Simplified AWV checklist
- Stanford Health Care: Sample HRA patient form
CMS does not require providers to use specific screening tools for AWV components and elements. For example, the cognitive assessment may be evaluated informally or using evidence-based tools.
ThoroughCare includes the following assessments as a sampling from the Annual Wellness Visit toolset. Recommendations from the American Academy of Family Physicians informed these.
- CAGE Questionnaire screens for alcohol use disorder
- DAST-10 (Drug Abuse Screening Test) provides a quantitative index of the degree of consequences related to drug abuse
- MDQ (Mood Disorder Questionnaire) screens for Bipolar Spectrum Disorder
- PAC (Post-acute care assessment) measures general functional status after an inpatient stay
- PHQ-2 or PHQ-9 (Patient Health Questionnaire) inquires about the frequency of depressive symptoms over the past two weeks
- GAD-7 (Generalized Anxiety Disorder Assessment) provides a seven-item instrument to measure the severity of generalized anxiety disorder symptoms over the past two weeks
- The cognitive assessment tests memory and recall, using a three-word list of unrelated words and an evaluation of a clock drawing task
- An ADL (Activities of Daily Living) assessment measures a person’s functional status and ability to perform daily self-care activities independently
3. Which billing codes? Creating accurate, compliant, and reimbursable billing
Once the IPPE or AWV is complete, staff can bill CMS for the visit. Figure 4 highlights each visit type, its HCPCS code and the 2025 national rate. A provider’s bill will depend on their geographic practice cost index, which adjusts the national average fee to reflect variations in practice costs across the US.
CMS also covers various optional services as part of each type of AWV, as shown in Figure 4. IPPEs may also include ECGs, AAA screens, or female screenings when appropriate.
AWVs may include optional Advance Care Planning or an SDOH assessment.
Figure 4: Medicare Annual Wellness Visit 2025 billing codes and optional services.
As shown in Figure 4, rural providers, such as Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), should bill all three types of AWVs under the HCPCS code G0468.
According to the Rural Health Information Hub, G0468 covers an FQHC visit that includes an Initial Preventive Physical Exam or Annual Wellness Visit. It consists of the typical bundle of services that would be furnished per diem to a Medicare beneficiary. This includes all services that would otherwise be billed as a FQHC visit under G0466 or G0467.
4. What’s next? Eligibility and enrollment into other care management programs
Annual Wellness Visits present a unique opportunity to identify which beneficiaries could benefit from available care management programs, such as Chronic Care Management.
Providers can use this or similar programs to coordinate ongoing patient care and improve outcomes. They can also generate additional revenue to further scale preventive health programs.
Figure 5 outlines the basic eligibility requirements for the primary programs reimbursed by CMS and available through ThoroughCare. ThoroughCare allows authorized care team members to enroll patients into any care management program and begin coordinating care activities in real-time.
Figure 5: Beneficiary eligibility criteria across Medicare care management programs.
ThoroughCare streamlines Annual Wellness Visits
ThoroughCare offers an end-to-end workflow for Annual Wellness Visits. Our software platform adheres to CMS requirements, tracks all reportable activities, and simplifies claim preparation. We also enable providers to pair AWVs with add-on services, such as Advance Care Planning and HRSN screenings, to maximize the value of wellness visits.
ThoroughCare streamlines AWVs through:
- Interactive health risk assessments
- Screening tools, such as ADL, CAGE, DAST-10, GAD-7, MDQ, PAC, PHQ-2, and a mini cognitive exam
- Care gap summaries with recommended interventions
- Personalized prevention plans
- Seamless enrollment in care management programs
- Automated CPT code assignment for accurate billing
Key questions answered
How can providers deliver Annual Wellness Visits efficiently?
When addressed systematically, four areas of focus can help providers streamline Annual Wellness Visits:
- Identifying eligible patients
- Delivering required activities
- Creating accurate and compliant billing
- Using the AWV as an enrollment opportunity for medically necessary care management programs