Annual Wellness Visit (AWV)

The purpose of the AWV is to review the patient’s wellness and develop a personalized prevention plan. Humhealth Annual Wellness Visit image

1. Acquire Beneficiary information

  • a. Administer HRA
  • b. Establish the beneficiary’s medical/family history
  • c. Review the beneficiary’s potential risk factors for depression, including current or past experiences with depression or other mood disorders
  • d. Review the beneficiary’s functional ability and level of safety

2. Begin Assessment

  • a. Health Risk Assessment 1) CAGE Questionnaire 2) Activities of Daily Living 3) Instrumental Activities of Daily Living
  • b. Cognitive impairment assessment
  • c. PHQ-2 and PHQ-9 Depression assessment

3. Counsel Beneficiary

  • a. Establish a written screening schedule for the beneficiary, such as a checklist for the next 5 to 10 years, as appropriate
  • b. Establish a list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended or underway for the beneficiary
  • c. Furnish personalized health advice to the beneficiary and appropriate referrals to health education or preventive counselling services or programs
  • d. Furnish, at the discretion of the beneficiary, advance care planning services
Humhealth awv screenshot

Key Features

  • Health Risk Assessment

    Health Risk Assessment

  • Cognitive impairment assessment

    Cognitive impairment assessment

  • PHQ-2 and PHQ-9 Depression assessment

    PHQ-2 and PHQ-9 Depression assessment

  • Functional Ability and Level of Safety

    Functional Ability and Level of Safety

  • Beneficiary Checklist for the next 5 to 10 years

    Beneficiary Checklist for the next 5 to 10 years

  • Auto Generation of Recommendations

    Auto Generation of Recommendations

HCPCS Codes and Descriptors

  • HCPCS Code
  • Billing Code Descriptors
  • Average Reimbursement

Behavioral Health Integration (BHI) Services

Integrating behavioral health care with primary care (“behavioral health integration” or “BHI”) is an effective strategy for improving outcomes for people with mental or behavioral health conditions.

Types of BHI Services

  • 1. General
  • 2. Psychiatric Coordinated Care Management (CoCM)

Care team members

  • 1. Treating (Billing) Practitioner
  • 2. Beneficiary
  • 3. Potential Clinical Staff

Service Components

Initial assessment

  • Initiating visit (if required, separately billed)
  • Administration of applicable validated rating scale(s)
  • Systematic assessment and monitoring, using applicable validated clinical rating scales
  • Care planning by the primary care team jointly with the beneficiary, with care plan revision for patients, whose condition is not improving
  • Facilitation and coordination of behavioral health treatment
  • Continuous relationship with a designated member of the care team

Principal Care Management (PCM)

Principal Care Management is also known as PCM and it is very similar to Medicare’s Chronic Care Management (CCM) with a few key differences. Under the new PCM codes, specialists may now be reimbursed for providing their patients with care management services that are more targeted within their own particular area of specialty. This program addresses the need for classification of treatment for patients with one chronic condition.

Transitional Care Management (TCM)

Humhealth Annual Wellness Visit image


Humhealth awv screenshot
  • Remote Patient Monitoring workflow 1


    Discharged from Hospital

  • Patient Monitoring workflow 2


    Interactive Contact

  • Remote Patient Monitoring workflow 3


    Face-to-Face Visit

  • Remote Patient Monitoring Devices workflow 4


    TCM Completed

TCM Workflow

Humhealth awv screenshot