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Risk Coding

Risk Coding Tips – June 2022

Annual Wellness Visit (AWV) and/or Comprehensive Physical Exam (CPE) encounters present an opportunity to evaluate your patient’s chronic conditions and HCC diagnosis codes. 

As a provider, you assess, review and adjust your plan for a patient based on their medications, review of laboratory and radiographic reports, reported symptoms and/or physical findings. If your EMR prompts you to review past medical conditions, you should also add the appropriate diagnoses that you review and discuss with the patient, or those which factor into your medical decision-making. 

Some payers allow Medicare Advantage patients to receive both the AWV and CPE during the same encounter, while others do not. At minimum, select the appropriate E&M code for the visit you are providing. See the chart below titled “Who Pays for What” for more information.

If your patient has an acute or new diagnosis they wish to discuss during their annual visit, you need to add an additional E&M code with a 25 modifier to the visit. We recommend that you work within your practice’s current guidelines regarding the use of the 25 modifier when reviewing highly complex patients.

Who Pays for What

Table comparing E&M Code, Visit Type Common Name, CMS Medicare, Medicare Advantage, Colorado Medicaid