A Top of License Approach to Unburdening PCPs and Increasing Annual Wellness Visits

From the 2021 HVPAA National Conference

Tiffany Wandy (LifeBridge Health), Jonathan Thierman, Jonathan Moles, Kristy Fogle


Annual Wellness Visits are a critical component of achieving success in value-based contracts focused on both traditional Medicare patients, as well as Medicare Advantage patients.


The purpose of this initiative is to increase Annual Wellness Visits (AWV) for Medicare (both traditional Medicare and Medicare Advantage) patients among our employed primary care providers. The goal is for at least 75% of eligible patients to receive an AWV annually.


APPs at the Virtual Hospital reach out to all patients with follow up visits scheduled with their PCP within the next month. The Virtual Hospital provider lets the patient know that they’re calling on behalf of the PCP in preparation for an upcoming appointment. The Virtual Hospital provider then conducts all of the screenings and documentation necessary for an AWV.

When the patient sees his/her PCP for the scheduled follow up visit, the PCP sees that the documentation for an AWV has already been completed in Cerner. Any urgent issues identified during the pre-visit meeting are communicated to the PCP via a red flag message in Cerner. During the visit, the PCP reviews the information as relevant with the patient and completes any additional documentation as needed.

For those patients who have a stand-alone AWV scheduled, the Virtual Hospital completes all of the pre-visit documentation as outlined above, which then frees the provider up to furnish additional services during that visit that he/she normally wouldn’t have time for. These services do not incur an additional charge for the patient when performed during the AWV.

Examples of these additional services are as follows:

  • Alcohol misuse annual screening, G0442
  • Behavioral counseling for alcohol misuse, G0443
  • Intensive behavioral therapy for cardiovascular disease, G0446
  • Annual depression screening, G0444
  • Low-dose CT counseling, G0297
  • Obesity counseling, G0447
  • Smoking and tobacco cessation counseling, 99406
  • Advance care planning, 99497


To date, 324 AWVs for Medicare patients have been completed and 55 AWVs have been completed for Medicare Advantage members. Feedback from both patients and providers has been very positive, with both groups focusing on the benefit of having a more focused office visit that can be spent reviewing the information collected in depth, rather than spending the majority of the time collecting the information.


Partnering with centralized APPs is an effective way to increase the number of AWVs conducted and increase both patient and provider satisfaction with the process.

Clinical Implications

  • Maintaining and increasing attribution. For many value-based care programs- MDPCP included- Annual Wellness Visits are a key driving factor for attributing patients to PCPs.
  • Closing gaps in care. The Annual Wellness Visit is a special visit to focus on the patient’s healthcare strategy and close gaps in care that may have been missed during regular office visits.
  • Capturing patient complexity. The Annual Wellness Visit is a great opportunity to ensure that the patient’s true complexity is captured in your documentation. This is important because it drives appropriate risk tiering for your MDPCP patients.
  • Driving patient engagement. Annual Wellness Visits are free for patients and can be conducted via video or telephone, offering additional opportunities to engage your patients who may be reluctant to come to the office but could still benefit from this type of interaction.

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