Medicare Annual Wellness Visit Components for a 65-Year-Old Female

Core Medical Assessment Components

The American Diabetes Association recommends a medical history review including family history of autoimmune disorders, complications, and common comorbidities such as obesity, obstructive sleep apnea, and non-alcoholic fatty liver disease 1
A medication review including assessment of medication-taking behavior, potential rationing of medications, medication intolerance, and side effects is recommended 1
Physical measurements including height, weight, BMI calculation, and blood pressure determination should be performed 1
Cognitive assessment using validated screening tools such as the Mini-Cog test, which has a sensitivity of 76% and specificity of 89% for identifying possible dementia, is recommended 2
Depression screening using validated tools such as the Patient Health Questionnaire-2 (PHQ-2) or Patient Health Questionnaire-9 (PHQ-9) should be performed 2
Functional assessment to evaluate activities of daily living and mobility, particularly important for patients 65 years and older, is recommended 2

The American College of Obstetricians and Gynecologists recommends cervical cancer screening with cervical cytology (Pap smear) every 3 years, or for women aged 30-65 years, screening with a combination of cytology and HPV testing every 5 years 3
Clinical breast examination should be performed annually for women aged >19 years according to ACOG recommendations 3
Mammography screening should be performed biennially for women aged 50-74 years 3
Lipid profile including total, LDL, and HDL cholesterol and triglycerides should be performed if not done within the past year 1
Diabetes screening with A1C testing should be performed if not available within the past 3 months 1
Bone health assessment including calcium, vitamin D, and phosphorous levels should be performed when appropriate 1

Social determinants of health assessment including food security, housing stability, transportation access, financial security, and community safety should be performed 1
Tobacco, alcohol, and substance use screening with appropriate counseling is recommended 1
Physical activity and sleep behaviors assessment, including screening for obstructive sleep apnea, should be performed 1
Eating patterns and weight history review is recommended 1

Personalized prevention plan development based on identified risk factors and health needs is recommended 4, 5
Referrals to health education and prevention counseling services should be made as needed based on screening results 4
Advance care planning discussions including identifying surrogate decision makers should be performed 1

BRCA risk assessment by asking about family history suggestive of increased risk for deleterious mutations in BRCA1 or BRCA2 genes, with referral for genetic counseling if risk factors are identified, is recommended 3
Counseling about risk-reducing medications for women at increased risk for breast cancer should be performed 3
Osteoporosis screening is particularly important for postmenopausal women 1

Avoid substituting brief physical examinations for the comprehensive preventive services required by Medicare 6
Mental health screening is a critical component of the wellness visit and should not be neglected 2, 7
Focusing solely on physical health while neglecting behavioral and social aspects of health should be avoided 1