Page 274 - Medicare Benefit Policy Manual

b. can be administered independently by the beneficiary or administered by a
health professional prior to or as part of the AWV encounter.

c. is appropriately tailored to and takes into account the communication needs of
underserved populations, persons with limited English proficiency, and persons
with health literacy needs.

d. takes no more than 20 minutes to complete.

e. addresses, at a minimum, the following topics:

1. demographic data, including but not limited to age, gender, race, and
ethnicity.

2. self assessment of health status, frailty, and physical functioning.

3. psychosocial risks, including but not limited to, depression/life satisfaction,
stress, anger, loneliness/social isolation, pain, and fatigue.

4. Behavioral risks, including but not limited to, tobacco use, physical
activity, nutrition and oral health, alcohol consumption, sexual health, motor
vehicle safety (seat belt use), and home safety.

5. Activities of daily living (ADLs), including but not limited to, dressing,
feeding, toileting, grooming, physical ambulation (including balance/risk of
falls), and bathing.

6. Instrumental activities of daily living (IADLs), including but not limited to,
shopping, food preparation, using the telephone, housekeeping, laundry, mode
of transportation, responsibility for own medications, and ability to handle
finances.

Review of the individual’s functional ability and level of safety: At a minimum,
includes assessment of the following topics:

a. Hearing impairment,

b. Ability to successfully perform activities of daily living,

c. Fall risk, and,

d. Home safety.