Make every AWV count: Don’t overlook chronic conditions.
Posted 10/05/26
What should you document?
A few extra minutes of documentation can make a meaningful difference.
The Medicare Annual Wellness Visit (AWV) is more than a preventive checklist. It is an opportunity to review the patient’s overall health, identify risks, and ensure the medical record accurately reflects current chronic conditions.
During the AWV, take a moment to review chronic conditions and document those that are current, clinically relevant, and addressed during the visit.
When appropriate, clearly capture:
- The condition being evaluated or addressed
- Current status — such as stable, controlled, worsening, or improving
- Relevant assessment or findings
- Treatment, monitoring, or follow-up plan
Provider tip.
Carry diagnoses forward in the medical record if appropriate. If a chronic condition is relevant to the patient’s care, briefly document how you assessed and addressed it and what the plan is.
See the difference.
Too vague:
Diabetes — continue current medications.
More complete:
Type 2 diabetes mellitus — stable on current regimen. A1c reviewed; continue current medications and monitor glucose. Follow up as scheduled.
The second example provides clearer evidence that the condition was current, assessed, and addressed during the encounter.
Why it matters.
Accurate chronic condition documentation helps:
- Create a more complete picture of the patient’s health
- Support continuity and coordination of care
- Identify conditions requiring ongoing treatment, monitoring, or follow-up
- Ensure the medical record reflects the patient’s current health needs
- Supports accurate reimbursement by reflecting true patient acuity and care intensity
Remember: Our goal is to document accurately and completely the conditions that are supported by your assessment and the clinical record and are relevant to the patient’s ongoing care.
Please reach out for any additional documentation and coding support at [email protected].
