Medicare Annual Wellness Visits and Care Management: Documented, Coded, and Billed From One Chart

Two Medicare Programs That Run on the Same Chart

For a primary care practice with a Medicare panel, the annual wellness visit and care management between visits are two halves of the same job. Once a year you sit down with the patient, go through their health risks, screen for depression, falls, cognitive change, and substance use, talk about advance care planning, and hand them a written prevention plan. The rest of the year, for the patients with chronic conditions, someone on your team coordinates their care, keeps the care plan current, answers their calls, and documents the time. Medicare pays for both. Most practices leave a large share of it unbilled, not because the work is not happening but because the documentation and coding rules are unforgiving and the paperwork lives in too many places.

Hero EMR treats both as part of the chart. The wellness visit is a single structured block in the note that fills itself from what the chart already knows, tells you which visit Medicare pays today, and codes only what you documented. Care management (CCM, PCM, APCM, remote monitoring and behavioral health integration) runs from one hub with enrollment, consent, care plans, time, and month-end claims. This guide walks through both, with a video of each.

The Annual Wellness Visit, Start to Finish

One block covers the three Medicare preventive visits: the initial annual wellness visit (G0438), once in a lifetime; the subsequent annual wellness visit (G0439), once every 12 months after the first; and the Welcome to Medicare preventive visit (G0402), once, within the first 12 months of Part B. The feature is a single switch under Admin → Care programs, and it is off until a practice turns it on, so practices that do not do wellness visits see nothing new.

Before the visit: the health risk assessment comes back on its own

With the feature on, the practice gets a Medicare Health Risk Assessment questionnaire and a booking rule preset that sends it when a wellness visit is booked. The patient answers on their phone or computer before they arrive. When you open the visit, the answers are already sitting beside the note, along with any PHQ, STEADI, or AUDIT-C screens the patient completed for this visit. A nurse or medical assistant can also ask the screening questions in the office before you join; the patient's answers count either way.

Which visit does Medicare pay today?

The hardest part of a wellness visit is often knowing which one it is. The top of the block carries an eligibility line that answers that before you start, for example "Subsequent AWV due since 3/14/2026 · last AWV 3/14/2025 (billed by this practice) · Medicare checked 10/20/2026." It combines four sources:

• wellness visits your practice has billed;
• visits at other practices, which staff record with Record an outside wellness visit;
• history brought over from a previous EHR (Hero's athenaOne and Charm billing imports keep prior wellness visits as procedure history);
• the newest Medicare eligibility check, which, with the feature on, also asks Medicare for the patient's wellness visit dates and Part B start date.

The block applies Medicare's frequency rules on the visit's date of service, the same date Charge Capture bills. If an appointment was moved, the visit is checked, and its screens and health risk assessment are read, on the day it actually happens. Because the line shows when Medicare will next pay, a patient who wants the visit early can be given an Advance Beneficiary Notice before the visit rather than discovering the denial afterward. At completion, charge notes flag what still needs a decision: a frequency limit, a Medicare Advantage plan (which sets its own frequency), a payer that does not cover these codes (a preventive medicine visit is the usual alternative), or a missing required element.

The .awv block: the chart fills it, you finish it

Type .awv in the note, or start from one of the two wellness visit templates. The block opens with the keyboard already in it. Every section of the visit has a place: visit type and supervised staff, the health risk assessment, history and current providers, measurements, cognitive function, depression risk, functional ability and safety, fall risk, alcohol, tobacco, substance use and opioids, physical activity and nutrition, advance care planning, the prevention plan, and other services that day.

Nothing in the block has a default. An empty field means "not assessed," and the note prints only what you recorded, as plain sentences under section headings. That matters on audit: a wellness visit note full of templated normals that nobody asked about is exactly what reviewers look for. When a nurse or medical assistant did part of the visit under your direct supervision, you check that box and name them, and the note says so.

Codes come from what you documented, and nothing more

A coding line on the block keeps up as you work. When you complete the encounter, Charge Capture adds lines from what the block recorded, and every line has a Why this code explanation. Hero never adds a code from a template, a default, or a suggestion.

The guardrails are the point. Screening codes need their own minutes: a depression or alcohol screen the patient answered on a questionnaire, with no minutes recorded today, is not billed, and the coding strip asks you to record them. Hero does not add G0444, G0442, or G0443 when the patient already had the service that day, is within Medicare's yearly limit, or when Medicare's eligibility response shows a later next eligible date. A separate problem you evaluated and managed is coded as an office visit as usual, with modifier 25 added. Modifier 59 is never added by default. Diagnoses follow convention (Z00.00 or Z00.01, Z13.31 for depression screening, Z71.89 for advance care planning), and the quality-code strip suggests 1123F when advance care planning was discussed and an agent or directive is on record.

Advance care planning, timed

Advance care planning has its own timer in the block that adds to the face-to-face minutes, which you can edit. Under 16 minutes bills nothing; 16 to 45 minutes is 99497; each further 30 minutes adds a 99498. You record that the conversation was voluntary, who was present, and which documents you explained, and the note prints them exactly as recorded. On the same claim as an annual wellness visit, modifier 33 waives the patient's cost sharing.

The written prevention plan

Medicare requires the patient to leave with a written screening schedule. Choose Prevention plan on the block and Hero builds one from the patient's age, sex and history, your practice's care gaps, and what you recorded today. Use in note fills the screening schedule in the block; Print or Send to portal gives the patient a copy and records how it was given. The plan only uses records the user's role can view, and says plainly what it left out rather than showing a vaccine as due when the user cannot see the immunization record.

Wellness visits due, and the care gap that closes itself

The Wellness visits due list shows patients with Medicare whose wellness visit is due now, due within 60 days, never done, or not yet due, with the last visit, the next eligible date, the next booked appointment, and the primary provider. Filter by status or provider, open a chart, or book the visit from the row. With the feature on, the annual wellness visit also becomes a care gap, and a signed wellness visit note closes it even before the claim goes out.

Care Management Between Visits: CCM, PCM, and APCM

The wellness visit happens once a year. Chronic care management happens every month. In Hero EMR it lives in the Value-Based Care hub, opened from the toolbar, with tabs for Today, Programs, Remote monitoring, Quality & ACO, Month-end & claims, Reports, and Settings. Each program has its own rules, and the hub keeps them apart while letting your team work them from one place.

Enrollment and consent

From a patient's Care programs chip, Add program checks eligibility and recommends a program when recommendations are on. You confirm the qualifying conditions, the billing provider, and the payer, then choose how to collect consent: document verbal consent from a script that includes the patient's cost sharing, or send an e-consent to the patient portal. A sent invitation is pending, not consent, and Hero treats it that way. For a patient with a visit today, the care dock can offer the recommended program directly, which makes the annual wellness visit a natural moment to have the conversation. From the Programs tab, staff can assign care managers and send e-consent to a whole selection of patients at once.

Care plans that are reviewed, versioned, and delivered

A care plan starts with Draft from chart: problems, goals, interventions, and follow-up from the patient's record, with bracketed placeholders the editor will not let you forget to personalize. Staff can prepare a plan; an eligible clinician reviews and approves it. Each month, Refresh now prepares the monthly copy and shows every change as labeled Before and After text, with a preview of the patient PDF, before you approve the revision. Approved plans can be delivered to the patient portal by hand or automatically, and the hub shows when the patient viewed it. An empty care plan is never treated as reviewed, approved, or billing evidence.

Time that counts, and only time that counts

Each staff member gets a timer profile: Off (show progress only), Offer (let staff start the timer), or Auto (capture while working in the patient's chart), with default programs and activities and an idle pause. Optional assistance can suggest time from calls and patient messages, suggest activities from recorded chart work, and polish draft time notes; every suggestion starts off and still needs a person to confirm it before it counts. Month progress shows confirmed minutes against the next threshold, and when staff and physician time both qualify, you choose the billing role rather than combining totals.

Month-end and claims

Claim generation is its own opt-in. Under Claim policy you choose the day claims are generated and the day they are submitted, and set each claim family to Off, Review (approve before release), or Auto (release only items that pass every check). Monthly services are dated the last day of the service month, on the practice's calendar. The Month-end & claims tab groups held items by what must be resolved (missing consent, conditions, diagnoses, insurance, or a reviewed plan) and links straight to the fix. Each item opens to its supporting time, diagnoses, code lines, and event history, and the Outcomes view follows billed and paid amounts and anything that needs follow-up.

APCM, CCM, and the overlap rule

Advanced Primary Care Management bills a monthly code by tier (G0556, G0557, G0558) for patients whose care is delivered under the APCM model, and the same practitioner cannot bill it alongside CCM or PCM for the same patient in the same month. Hero applies one overlap rule everywhere: at month-end and in the care dock. A practice setting decides which one bills when they overlap for the same practitioner (whichever happens to run first never decides it), a month already on a claim is never undone, and a month-end item offers Bill CCM instead of APCM for a single patient-month when that is the right call. A voided APCM month frees the month for CCM. APCM bills from the care plan as it stood that month, holds a month whose plan came late for review, and says which months billed, which are waiting for review or were skipped, and why. The behavioral health add-ons (G0568, G0569, G0570) are in the code catalog with their one-per-month limit. Claims bill under the enrolled provider's department, and a practitioner with no department is held rather than billed under someone else.

Reports

Reports compare the program month over month: enrollment and growth, minutes by staff and profile, eligible patients not yet enrolled, and HCC review on the clinical side, plus revenue by program, claim outcomes, and work RVUs by provider for users with financial access. Most export to CSV.

How It Fits Together

The two programs feed each other. The wellness visits due list puts the year's preventive visit on the schedule. The health risk assessment, screens, and vitals arrive before the patient does, and the .awv block turns them into a visit that meets Medicare's required elements and is coded from what was actually done. The written prevention plan and the practice's care gaps carry the follow-up forward, and for patients with chronic conditions, the same visit is the natural place to enroll them in CCM or APCM, document consent, and start a care plan that the team will keep current every month. Month-end then turns the documented work into claims, with every hold explained.

Both features follow the same principle that runs through Hero EMR: the chart fills what the chart already knows, the clinician decides, and nothing is billed that was not documented. Practices turn each program on when they are ready; nothing appears until they do.