Workflow GuideAnnual Wellness Visits (AWV)

AWV & Chronic Care Monthly Check-In Workflow Guide

Optimize your Annual Wellness Visit (AWV) and APCM revenue with this automated chronic care monthly check-in and enrollment workflow for primary care.

Transform your Annual Wellness Visits from a one-time screening into a continuous revenue engine. By integrating AWV with Advanced Primary Care Management (APCM), practices can capture over $700 per patient annually. This workflow leverages AI automation to schedule AWVs, complete HRAs, and seamlessly enroll eligible chronic care patients into monthly monitoring programs.

The Challenge

Most practices miss over 50% of AWV opportunities and fail to bridge the gap between the annual visit and monthly APCM billing, leading to fragmented care and significant lost revenue from eligible Medicare patients who require more consistent chronic care management.

Step-by-Step Workflow

1

Automated Outreach & Eligibility Check

Utilize AI call handling to scan your EHR for Medicare patients due for G0438 or G0439 and trigger automated, personalized scheduling calls to fill your calendar.

Best Practices
  • Target patients at the 11-month mark to ensure year-over-year compliance
  • Use AI to verify Medicare Part B eligibility before the call
Common Pitfalls
  • Waiting for patients to call you to schedule their annual visit
2

AI-Powered Pre-Visit HRA Collection

Deploy an AI voice assistant to complete the Health Risk Assessment (HRA) over the phone 48 hours before the visit, capturing vital social determinants and chronic condition status.

Best Practices
  • Sync HRA data directly into the EHR to save clinical staff 15 minutes per visit
  • Identify high-risk flags for APCM eligibility during the HRA
Common Pitfalls
  • Handing the patient a paper HRA form in the waiting room
3

AWV-to-APCM Gap Analysis

Review the AI-generated HRA summary to identify patients with two or more chronic conditions that qualify for APCM enrollment during their scheduled AWV encounter.

Best Practices
  • Flag patients with hypertension, diabetes, or COPD for immediate enrollment
  • Prepare the APCM consent forms alongside the AWV documentation
Common Pitfalls
  • Missing the opportunity to enroll patients while they are physically in the office
4

The Integrated AWV & Care Plan Initiation

Perform the AWV and use the gathered HRA data to satisfy the initial care plan requirement for APCM, effectively performing the work for two billing codes in one visit.

Best Practices
  • Document the transition from the AWV preventive plan to the APCM chronic plan
  • Ensure the provider reviews the HRA findings with the patient
Common Pitfalls
  • Treating the AWV and APCM as separate, disconnected clinical events
5

Same-Day APCM Enrollment & Consent

Secure and document patient consent for APCM services during the AWV checkout process, utilizing the momentum of the annual visit to improve enrollment rates.

Best Practices
  • Explain the benefits of monthly AI-driven check-ins for their chronic conditions
  • Provide a clear handout on what to expect from monthly APCM monitoring
Common Pitfalls
  • Failing to document verbal or written consent required for APCM billing
6

Automated Monthly Check-In Trigger

Schedule the first AI-driven monthly check-in call exactly 30 days after the AWV to maintain APCM compliance and monitor the patient's adherence to the care plan.

Best Practices
  • Set up automated alerts for clinical staff if a patient reports a decline
  • Use AI to capture the required 20 minutes of non-face-to-face time
Common Pitfalls
  • Relying on manual staff calls to hit monthly APCM time requirements
7

Revenue Stacking & Billing Submission

Submit G0438/G0439 for the AWV and initiate the first monthly APCM billing cycle, ensuring all documentation reflects the integrated nature of the care.

Best Practices
  • Audit your billing to ensure both the AWV and APCM codes are captured
  • Track the $700+ annual revenue growth per patient in your financial dashboard
Common Pitfalls
  • Under-coding the AWV or forgetting to trigger the first month of APCM

Expected Outcomes

1

Increased AWV completion rates above 80% through automated scheduling

2

Higher APCM enrollment from the AWV pipeline using HRA data

3

Maximized annual revenue per Medicare patient exceeding $700

4

Reduced administrative burden via AI-driven HRA collection and check-ins

5

Improved patient outcomes through continuous monthly chronic monitoring

Frequently Asked Questions

Yes, Medicare allows concurrent billing of AWV (G0438/G0439) and APCM services if all documentation requirements for both are met during the encounter.

AI voice assistants can conduct the HRA via phone before the visit, ensuring the provider has all data points ready to build the APCM care plan during the AWV.

Combining an AWV with monthly APCM enrollment can generate over $700 per patient annually, compared to just $170 for a standalone AWV.

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AWV & Chronic Care Monthly Check-In Workflow Guide | Tile Health