Annual Wellness Visits: Heart of a value-based CDI program

Once you’ve put in the considerable legwork to get your value-based/ambulatory CDI program approved, and you’re ready to begin, where do you start?

As noted in our previous article in this series, we recommend you start small. A great way to begin is with a prospective review of patients coming in for their Annual Wellness Visit (AWV).

Success in the world of value-based CDI requires out-of-the-box thinking, and we outline one such strategy below—using nurse CDI specialists as part of the AWV itself. This sets up a great process for pre-screen/prospective review and compliant provider query/clarification.

Read on to learn more.

What are AWVs?

AWVs are once annual visits covered by Medicare. They require no deductible or co-pays. AWVs are detailed, question-based assessments of a patient’s current health and risk factors, performed in a face-to-face encounter. Physicians review the individual’s medical and family history, and typically perform height, weight, BMI, waist circumference, and blood pressure measurements. 

During an AWV physicians may also document future resource needs and other social determinants of health, including food insecurities, domestic situations, that can impact care and cost. 

If used properly, AWVs are a win-win for providers and healthcare organizations. AWVs can help providers:

  • Generate additional revenue (via split billing; physicians can submit a separate CPT code for professional fees)
  • Achieve quality measures under the Merit-Based Incentive Payment System (MIPS)
  • Assess the current treatment plan without focusing on trying to diagnose new issues
  • Generate awareness for need of ancillary services
  • Generate documentation necessary for completion of Medicare Advantage and Part D star ratings, including quality of care and customer service
  • Highlight social determinants of health (1)

If your organization has an outpatient CDI program, AWVs expedite the process of capturing accurate risk adjustment diagnoses. Obesity, chronic depression, diabetes, CHF, and other chronic conditions can be recaptured for annual reporting in this setting.

This all sounds great, and it is, but providers often don’t emphasize AWV documentation. It becomes just another priority, and burdensome ask, among many others.

Moreover, many organizations don’t rigorously schedule AWVs, or suffer from patient no-shows. Adoption of the AWV has been modest, with an estimated 24% of eligible beneficiaries receiving an AWV in 2017 (2). This indicates untapped potential.

In short, AWVs are perfect time and place for a CDI to pre-review the visit for any chronic conditions that may need to be recaptured for Hierarchical Condition Category (HCC) assignment. But it takes a good process and trackable metrics to ensure you’re on the right path.

Next we’ll show you the why, and how.

Why: The role of CDI in AWVs

CDI professionals can step into this gap and make AMVs a win-win for providers and hospitals. Due to their ability to bridge the gap between clinical and coding worlds, nurse CDI professionals are a great fit for this responsibility. Nurses are authorized by Medicare to perform AWVs and can perform this responsibility, while simultaneously serving documentation needs.

“I propose we could do this, I propose we should do this, and I propose that we can do this abiding by all the rules,” says Dr. Jessica Vaughn, DNP, RN, CCDS, CCDS-O, CRC, vice president of value-based CDI for Norwood. “I truly think that CDI needs to be recognized amongst clinical professions across the healthcare continuum, and that coding professionals should also be elevated to be part of the care team and recognized as such. I think that’s what we have to do, to move to value-based care.”

The evidence is clear for a strong process whereby AWVs are scheduled, performed, and documented by RN CDI specialists. Vaughn, who recently completed two years of research on nurse-led AWVs, discovered the following positive impacts on patient care and reduced overall healthcare costs:

  • Fewer acute care visits for patients, who receive preventative treatment in less costly settings (2) 
  • Improved quality outcomes in the elder population, through community and primary care programs targeting chronic disease (3) 
  • Improved health outcomes and reduced cost through prioritized preventative care (4) 

In addition, patients obtaining multiple, consecutive preventative visits use ancillary services more but have less associated costs overall (5). “This is a great sell to your CFO,” Vaughn says.

How: Start with a pilot

Vaughn’s prior organization piloted a small AWV project to put these findings to the test. The organization selected five physicians in a single primary care clinic (four MDs, one APP) and focused on their visits. An experienced CDI RN (5-7 years in the CDI profession) would then:

  1. Review the chart prior to the patient’s arrival
  2. Meet and interview the patient using a health risk assessment, and complete the Medicare AWV questionnaire. The CDIs would not address themselves to the patient as CDI specialists, but nurses assisting the physician.
  3. Follow up with the provider with any necessary clarifications/queries, either electronically or via face-to-face conversation in the clinic. These questions included any clinical or care concerns the patient had, regardless of HCC status. 

The visit would then continue with the licensed healthcare provider, who would see the patient and answer any queries. This allowed for appropriate and compliant diagnosis capture as well as improved care continuity.

One roadblock was patient no-show rates; the organization, an academic medical center, was treating patients with severe chronic issues, but its pilot clinic was only capturing 11% of eligible patients’ AWVs in the past year, with a high of just 15% for a single year in a five-year audit window. 

Improving patient scheduling was prioritized. The organization tracked three principal metrics, including:

  1. Number of AWVs completed
  2. RAF capture
  3. Quality and care gaps capture


Just a few months into the pilot improvements were already visible. The project kicked off in September with a 75.62% chronic RAF capture. By December chronic RAF capture moved nearly 5 percentage points, to 80.26%–short of a goal of 90%, but a large improvement, nonetheless. Expanding across all clinics, that number improved to 85%.

As of Q1 2022, the pilot clinic is tracking a 57% capture rate, pacing toward a 100% capture rate by year’s end. This closely mirrors the other clinics in the system.

The pilot clinic also doubled its AWV completion rate, moving from just 13% in 2020 to 26% in 2021.

Quality and care gaps are being tracked by the quality department and statistical data is not presently available. But, anecdotal evidence points to improved care, including identification of a DVT by a CDI nurse.

The success of the pilot lowered barriers for implementation in additional clinics throughout the system. Physicians began to ask for the same type of assistance in their own practice. 

Patients also reported a better experience; because the CDI performed the questionnaire, they could spend more time talking to their physician and engaging in dialogue, rather than answering rote questions. This has the side benefit of improved star ratings related to patient experience.

Interested in learning more, or implementing your own value-based CDI pilot? The experts at Norwood can help you get there. Send an email to Jessica Vaughn at, or connect with her here on LinkedIn, even if you have questions about this article or need a bit of advice.


About Jessica Vaughn 

Jessica Vaughn, DNP, RN, CCDS, CCDS-O, CRC, is Vice President, Value-Based CDI for Norwood. She has more than 11 years of CDI experience and 25 years of nursing experience. In 2015 she started and led one of the nation’s first successful outpatient programs at Wake Forest Baptist Health, focused on value-based care for Population Health. She is a leader in the industry, having spoken at multiple conferences, authored articles, received ACDIS’s National Professional Achievement Award in 2016, and helped write both the ACDIS CCDS-O study guide and the certification exam. Jessica recently earned her Doctorate of Nursing in Executive Leadership at Duke University. 

About the author 

Brian Murphy is the founder and former director of the Association of Clinical Documentation Integrity Specialists (2007-2022). In his current role as Branding Director of Norwood he enhances and elevates careers of mid-revenue cycle healthcare professionals.

Additional resources

View prior posts in our value-based CDI series:


  1. Understanding the benefits of annual wellness visits. Available at:  (2017)
  2. Misra A, Lloyd JT. Hospital utilization and expenditures among a nationally representative sample of Medicare fee-for-service beneficiaries 2 years after receipt of an annual wellness visit. Prev Med. 2019;129:105850. doi:10.1016/j.ypmed.2019.105850. Available at 
  3. Farford, B. A., Baggett, C. L., Paredes Molina, C. S., Ball, C. T., & Dover, C. M. (2020). Impact of an RN-led Medicare Annual Wellness Visit on preventive services in a family medicine practice. Journal of Applied Gerontology, 1(7). Available at:
  4. Joling et al., 2018; Kim et al., 2016; Massimi et al., 2017; Simpson & Kovich, 2019; Wenger et al., 2021
  5. Beckman et al., 2019; Castaldi & McNelis, 2019; Farford et al., 2021
  6. Beckman et al., 2019; Chung, et al., 2018; Simpson & Kovich, 2019

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