Medical Transcription Services to Meet Annual Wellness Visit Documentation Requirements

Medical Transcription Services to Meet Annual Wellness Visit Documentation Requirements

Medical transcription services can ensure efficient documentation of all the details involved in the Annual Wellness Visit.

MTS Transcription Services 8596 E. 101st Street, Suite H Tulsa, OK 74133

www.medicaltranscriptionservicecompany.com

(800) 670 2809

The Annual Wellness Visit (AWV) provides the physician the opportunity to develop a personalized prevention plan for Medicare beneficiaries. However, many health systems do not deliver sufficient AWVs to Medicare patients because of the burdensome documentation

requirements,

according

to

a

report

in

advisory.com.

Medical

transcription services are a practical solution when it comes to reporting the components of a Medicare AWV. AWV Documentation Requirements Though it is similar to the annual physical, the AWV focuses on what the patient's current condition is as well as on what screenings and other preventive services (such as vaccinations) the patient might need based on his or her current health. Therefore, the documentation rules for these encounters are different. The components of the documentation of a first time beneficiary for the Medicare AWV are as follows: 

Acquiring beneficiary information

Self-reported

information

from

the

beneficiary:

This

involves

documentation

of

demographic data, self-assessment of health status, psychosocial risks, behavioural risks, and activities of Daily Living (ADLs).

Medical/family history: The physician has to record medical/family history such as medical events in the patient’s parents, siblings, and children and hereditary diseases or those that pose an increased risk for the beneficiary. The provider should also note past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries and treatments, and use of/exposure to medications and supplements.

Review of beneficiary’s potential risk factors for depression: Documentation should cover the patient’s current or past experiences with mood disorders. The provider can use nationally recognized screening tools to screen patients without a current diagnosis of depression.

Review of the individual’s functional ability and level of safety: This includes ability to perform ADLs, fall risk, hearing impairment, and home safety. 

Assessment

Assessment of the patient can commence after all the beneficiary information is obtained.

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(800) 670 2809

Routine measurements: The patient’s routine measurements should be noted including height, weight, blood pressure, and body mass index (BMI). Based on family history, other measurements would also need to be assessed Detection of cognitive impairments: This involves identifying and documenting any cognitive impairment the beneficiary may have through direct observation as well as information from other relevant sources. 

Counselling

Screening schedule: A written screening schedule for the beneficiary should consist of a checklist for the next 5-10 years. The required elements of the schedule include: agebased preventive services that Medicare covers, recommendations from the US Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), and the beneficiary’s HRA, health status, and screening history.

List risk factors and proposed or on-going interventions: The list should include risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended or underway for the beneficiary.

Personalized health advice and referral: In addition to individualized health advice, counselling documentation should include referrals to programs aimed at communitybased lifestyle interventions to reduce health risks and promote self-management and wellness, fall prevention, nutrition, exercise, tobacco-use cessation, and weight loss.

Medical Transcription Outsourcing -- Reap the Benefits of EHR Optimization for AWVs An article in advisory.com describes the AWV as a great opportunity for electronic health record (EHR) optimization. The AWV is crucial for accurate risk adjustment which is important for health systems looking to take on risk-based contracts. This type of visit helps in the transition to value-based payment while also offering benefits under fee-forservice. Importantly, the AWV is a great tool to promote patient engagement. A professional medical transcription company can help physicians reap these benefits of medical

record

optimization

with

accurate

and

timely

EHR-integrated

AWV

documentation.

www.medicaltranscriptionservicecompany.com

(800) 670 2809