Per the Medicare manual: Establishment of, or an update to, the individual’s medical/family history: At a minimum, the collection and documentation of the following: a. Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments.
b. Use or exposure to medications and supplements, including calcium and vitamins.
c. Medical events in the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the individual at increased risk.
It is a requirement to at a minimum get the above information. If the patient does not know this information I would document the reason why such as "the patient was adopted and does not have any family history information" (but then should include children's information, if applicable). Or if the patient is not cognizant of their surroundings or forgetful of the information, the provider should find information about the patient such as asking a caregiver or family member.
The purpose of an AWV is to establish the instances where a patient could have some problems, keep an eye on them, and scheduled required and/or necessary testing for the patient. So this information is required.
But all requirements must be met in order to bill the AWV visit. Otherwise you bill under the CPT code that best represents the information provided. (And MC does not pay for preventive services for patients).
