RN - Annual Wellness Visit

Subjective

[For each health issue discussed, provide a detailed but concise set of information in story format. Present each problem in its own paragraph, maintaining a narrative style. Include current symptoms, history, medication use or changes, other specialists visited, and a brief summary of any concerns related to that specific problem. Ensure that each paragraph is concise and factual, focusing on one specific problem at a time to improve readability.] **Medicare Wellness Intake Visit:** [Provide a clinician's HPI summary that identifies risks related to the wellness exam. Mention specific problems but exclude the plan of care, which should be included only in the Assessment and Plan (AP) section.]

Subjective

[For each health issue discussed, provide a detailed but concise set of information in story format. Present each problem in its own paragraph, maintaining a narrative style. Include current symptoms, history, medication use or changes, other specialists visited, and a brief summary of any concerns related to that specific problem. Ensure that each paragraph is concise and factual, focusing on one specific problem at a time to improve readability.] **Medicare Wellness Intake Visit:** [Provide a clinician's HPI summary that identifies risks related to the wellness exam. Mention specific problems but exclude the plan of care, which should be included only in the Assessment and Plan (AP) section.]

Objective

[Document physical examination findings when only when mentioned in this section, but results review for imaging should be discussed in the HPI section. Make this section only clinical bullet points related to physical exam]

Objective

[Document physical examination findings when only when mentioned in this section, but results review for imaging should be discussed in the HPI section. Make this section only clinical bullet points related to physical exam]

Assessment & Plan

[Begin with Medicare wellness exam essentials, including risk assessments and counseling. Document the time spent on each counseling session, prioritizing weight loss, tobacco cessation, and alcohol cessation counseling, and advanced care planning. Include BMI diagnosis if weight and obesity are mentioned, and document "weight loss counseling provided today x15 minutes." For smoking, if a continuous problem, diagnose nicotine dependence and document "tobacco cessation counseling provided x5 minutes." For alcohol intake, if identified as a risk factor or problem, document alcohol dependence and "alcohol cessation counseling x10 minutes."] [After Medicare essentials, summarize specific clinical areas with adjusted plans. Provide a summary of the most important problems in bullet format with a very brief assessment. Exclude lengthy descriptions in the plan and specifics on medication changes. Include differential diagnosis if other possible options are mentioned but do not include patient concerns as a possible diagnosis. Separate the assessment and plan for each diagnosis. If beyond 4 important issues are discussed, summarize them much more briefly and keep them in a final section called "Other Issues Discussed."] [For example: [n. Diagnosis n]: - [Brief recommended treatment and management plan] - [Referral details and further assessment plans only when medically appropriate] - [Patient education and lifestyle modifications] - [Follow up details] [always capture the instructions given to patient on "follow up in clinic if this is a persistent or worsening issue"]

Billing Notes

[Include both commercial and Medicare reimbursable CPT and quality care codes for wellness visits. Focus on procedures performed and any extensive visits requiring more than level 4 visits. Exclude non-reimbursable counseling details. Use single line entries for each procedure or CPT code recommended. If records request is mentioned, add "ROI" with the office or physician records needed from. Format the entries in a bulleted list for clarity and quick data entry by the billing team.]

Suggestions

[In this section, focus on highlighting diagnoses used, emphasizing ICD10 codes that are heavily weighted. Allow providers to evaluate and potentially change the diagnosis codes before finalizing the note. Document other related diagnoses that may have been overlooked but are appropriate for HCC coding. Include the relevant ICD10 codes and explain why they are appropriate. Additionally, suggest any extra CPT codes that could add reimbursement value to the clinical note. Use a narrative paragraph style to ensure clarity and coherence.]