Annual Wellness Visits and Chronic Care Management Frequently Asked Questions


Q: How are patients being scheduled for their Annual Wellness Visit? 

A: Patients can either be scheduled to come in 15-20 minutes prior to their appointment to complete the Annual Wellness Visit or be scheduled to come into the office specifically for the Annual Wellness Visit if the appointment volume is low The 40-question Health Risk Assessment can be completed prior to the visit either telephonically, electronically via email, or on a tablet given to them in the waiting room. 

Q: Is the Annual Wellness Visit the same as the Annual Physical Exam?

A: No, the Annual Wellness Visit (G0438, G0439) is different than the Annual Physical Exam and cannot be billed on the same day. Care Coordinator checks the patients’ eligibility on verification site to see if what type of exam they are due for as some patients have already completed their Annual Wellness Visit (G0438 or G0439) for the year and are not eligible until next year.  An Annual Physical Exam can only be performed by the patient’s billing practitioner. 

Q: Who can be enrolled in the Chronic Care Management (CCM) program?

A: Medicare patients with 2 or more chronic conditions are eligible for enrollment in the Chronic Care Management (CCM) program. 

Q: How are patients enrolled in CCM?

A: There are various ways patients can be enrolled in CCM. 

  • Care Coordinator can enroll patients during the Annual Wellness Visit

  • Provider can refer their patients to CCM using the CCM Referral cards

  • Provider refers their patients into CCM program and the referral card is given to the Care Coordinator for enrollment

  • Telephonically – patients who have been seen within the past year can be enrolled telephonically. Care Coordinator calls out to qualified patients for enrollment

  • Promotional materials – CCM marketing campaigns (flyers, emails, newsletters, etc) contain call to action for patients to call Care Coordinator to inquire about the program

Q: How will the practice know who is enrolled in CCM or completed the AWV?

A: A weekly report will be generated showing the patients enrolled in CCM and those who have completed the AWV. Report will be listed by Provider.

Q: What documentation is generated from CCM?

A: CCM Care Plans are created for each patient. Care Plans include goals based on the patient’s chronic condition, barriers that may keep them from reaching those goals, lists of current medications, problem symptoms, expected outcomes. Patients can receive an electronic copy of their Initial CCM Care Plan via HIPAA compliant portal/communication

Q: What can the patients expect from being enrolled in CCM?

A: A personalized Care Plan, monthly calls from the Care Coordinator to ensure they’re meeting the goals set in the Care Plan and track any barriers that may be preventing them from reaching the goals. The Care Plan will be continually updated as the Care Coordinator will be monitoring their activity and requests coming into the practice. 

Q: What if the Care Coordinator identifies an out-of-range reading or health data?

A: Any issues or out of range health data identified by the Care Coordinator will be reported immediately to the Provider’s MA or respective resource 

Q: What documentation is generated from AWV?

A: A Personalized Preventative Plan (PPPS) is created for each patient upon completion of the AWV. The PPPS contains risk factors identified based on the patient responses to questions in the Health Risk Assessment, summary of vitals, educational material on diet, exercise, and information specific to their chronic condition. 

Q: Where is the patient information from the AWV or CCM? 

A: All documentation lives in the CCM & AWV platform. All CCM Care Plans and Personalized Preventative Plans are available upon request. 


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