Using AWVs and CCM Together: Maximizing Preventive and Chronic Care

Mrs. Johnson’s Annual Wellness Visit (AWV) ends with a clean, prioritized prevention plan, yet her real progress will be decided over the next 364 days. That is exactly where Chronic Care Management (CCM) belongs: AWVs surface and rank what matters and CCM keeps those priorities moving month after month with outreach, monitoring, and course-corrections. This piece focuses on the operational handshake between AWVs and CCM, how to wire them together without friction, so an annual snapshot becomes continuous, measurable care.

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The operating model: AWV identifies, CCM operationalizes

An Annual Wellness Visit (AWV) gives you a structured, once-a-year snapshot of where each patient stands on prevention and chronic care. Chronic Care Management (CCM) is the engine that takes that snapshot and turns it into motion. Together, they create a continuous cycle: the AWV identifies what’s needed, and CCM ensures it gets done between visits:

Two different cadences, one shared plan

• AWV cadence (annual): A comprehensive review (CPT G0438 for the initial visit; CPT G0439 for subsequent visits) of preventive needs, risk factors, and chronic conditions, documented as a Personalized Prevention Plan (PPP). Think of this as your strategic blueprint.
• CCM cadence (monthly): Ongoing engagement to check tasks off the blueprint, adjust goals, and keep the patient moving forward. These monthly check-ins (CPT 99490 base 20 minutes; CPT 99439 per additional 20 minutes) ensure the AWV plan doesn’t sit idle.

Role clarity across the team

• Clinician responsibility in the AWV: Define the priorities, set measurable goals, and authorize the prevention and chronic care roadmap.
• Nurse/MA responsibility in CCM: Execute that roadmap with monthly touchpoints, under general supervision. They reconcile medications, check adherence, schedule labs and screenings, and flag escalations.
• Care coordinator/social worker involvement: Where available, these roles address social determinants identified during the AWV (transportation, cost barriers, housing issues) and track them over time in CCM.
  

Example: how the model works in practice

• At the AWV: Mr. Smith is identified as hypertensive, overdue for a colonoscopy, at risk for falls, and on 12 medications. His PPP outlines goals: lower BP to <130/80, complete colonoscopy within 90 days, review meds for de-prescribing, and address fall risk.
• In CCM:
  • Month 1: CCM nurse ensures colonoscopy referral is scheduled, provides home BP cuff, and calls to check understanding.
  • Month 2: Reviews BP readings, escalates uncontrolled values, checks whether colonoscopy prep has been scheduled, and runs med list for duplications.
  • Month 3: Confirms colonoscopy completion, reviews home safety checklist, and documents fall-prevention actions.
    

By month three, 75% of the AWV plan has been executed, with progress clearly logged for compliance and reporting.

Why the model matters

• Without CCM, AWV goals are too often just plans on paper.
• Without AWVs, CCM can feel like maintenance without direction.
• Together, AWVs give CCM meaning, and CCM gives AWVs staying power.
  

The feedback loop

Each subsequent AWV builds on CCM’s work: data collected over 12 months (BP logs, adherence history, completed referrals, fall risk reassessment) feeds into the next AWV, making it more precise. In turn, that new AWV refines CCM’s next year of monthly action items.

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A simple playbook for a handoff you can trust

The value of AWVs and CCM isn’t just in the services themselves, it’s in the handoff between them. A prevention plan that doesn’t translate into monthly action stalls, and a CCM program without fresh annual priorities risks spinning its wheels. The playbook below shows how to stitch them together reliably.

Before the AWV: set the stage

• EHR flagging. Run eligibility reports monthly in your EHR software to flag patients with ≥2 chronic conditions who are due for an AWV. Most modern EHRs allow you to tag patients: tag the patients you identify with your eligibility report as “CCM_candidate.”
• Pre-visit questionnaire. Send a short intake form or HRA that screens for falls, depression, adherence barriers, and social determinants. Route results to the CCM team to pre-plan potential follow-up.
• Staff briefing. In morning huddles, MAs and nurses review which patients are AWV+CCM candidates so they know to initiate enrollment discussions during the visit.

During the AWV: plant the seed and act

• Clinician role. While completing the prevention plan, the clinician highlights top 2-3 chronic priorities (e.g., “We need to bring your BP down, get your A1c checked quarterly, and schedule that eye exam”).
• Nurse/MA role. As the AWV wraps, the nurse/MA transitions seamlessly:
  • Introduce CCM: “Because you have two chronic conditions, Medicare offers a program where our nurse calls you each month to check your readings, medications, and appointments. This helps us make sure today’s plan actually happens.”
  • Consent and enrollment: Have a consent template ready in the AWV note. Document patient understanding, explain the small copay (if applicable), and secure electronic or written consent.
  • Immediate setup: Schedule the first CCM call before the patient leaves the clinic.

After the AWV: first 48 hours

• Mini action plan. The CCM nurse converts the AWV prevention plan into a 90-day “mini-roadmap” with monthly goals, tasks, and escalation triggers.
• Task assignment. Orders for labs, referrals, or device shipments are logged with due dates. Each task is assigned in the CCM dashboard with owner and deadline.
• Documentation sync. The AWV note is linked to the CCM care plan so there’s one continuous record.

Monthly CCM execution: keeping the handoff alive

• Check-in calls. Each month, the CCM nurse reviews progress on AWV priorities, closes outstanding tasks, and logs ≥20 minutes of clinically necessary non-face-to-face care.
• Escalation ladder. If BP averages are above threshold, labs are overdue, or the patient reports concerning symptoms, the nurse escalates to the clinician the same day.
• Barrier busting. Address transport, cost, or adherence problems identified at the AWV. Document resolutions for compliance and continuity.

Quality assurance for the handoff

• Consent audits. Verify CCM consents are captured during the AWV at least annually.
• Closure reports. Run monthly reports to track the % of AWV-generated tasks closed within 60 days.
• Handoff huddles. Weekly 15-minute CCM team huddles confirm that every AWV patient tagged as CCM_candidate has either been enrolled or formally opted out.

Pro tips to keep handoffs frictionless

• Use dot-phrases in the AWV template for CCM consent and program explanation to standardize scripting.
• Automate CCM referral orders so AWV completion triggers an enrollment task automatically in the EHR.
• Train staff to discuss CCM before checkout, when the patient is still in “planning mode.”
• Integrate scheduling: don’t leave it to the patient to call back, book the first CCM touchpoint immediately.
• The ultimate pro tip is to use Lara Health to run your CCM program and manage your AWVs. Lara Health is simply the most efficient, effective, and economically rewarding way to run CCM and to overlay a systematic AWV program from A to Z.

Bottom line: A great AWV without a CCM handoff is like drawing up a map but never starting the journey. A systematic handoff ensures every AWV patient with chronic disease leaves not only with a prevention plan but also with a monthly engine to keep that plan moving forward.

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Mapping the links between Annual Wellness Visit (AWV) and Chronic Care Management (CCM): from findings to ongoing work

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Time attribution and billing integrity (avoid audit traps)

When AWVs and CCM run side-by-side, the risk isn’t in delivering the care, it’s in how you log it. Misattribution of time or services is one of the top reasons practices face denials, clawbacks, or audit findings. A clean process avoids compliance headaches and ensures you capture every dollar you’ve earned.

1. The golden rule: never double-count minutes

• CCM (CPT 99490 / CPT 99439) covers 20+ minutes per month of non-face-to-face, medically necessary coordination and management by clinical staff under general supervision.
• RPM/RTM (CPT 99457 / CPT 99458; CPT 98980 / CPT 98981) cover review and interactive communication tied to device-based data.
• BHI (CPT 99484, CPT 99492-99494) covers structured behavioral health integration work.
• TCM (CPT 99495 / CPT 99496) covers care coordination in the 30 days post-discharge.
  

The same 5 minutes spent calling a patient about device readings cannot count for both RPM and CCM. The same depression screen counseling cannot be logged under both BHI and CCM. Document which code family the time belongs to and why.

2. Map minutes to activities

• CCM minutes: med reconciliation, scheduling labs, adherence coaching, SDOH resource coordination.
• RPM minutes: device data review, contacting patient about abnormal values, troubleshooting connectivity.
• BHI minutes: PHQ-9 review, care coordination with behavioral health specialist.
• TCM minutes: outreach within 2 business days of discharge, med reconciliation specific to the transition, follow-up scheduling.
  

Creating a minutes map poster or digital guide for your staff prevents overlap and ensures consistency across team members.

3. Document consent and supervision

• CCM requires documented patient consent (verbal or written). Capture it during the AWV and reference it in the note.
• General supervision means the billing practitioner doesn’t have to be physically present, but the service must be provided under their direction and oversight. Document who delivered the service, when, and under whose supervision.
  

4. Monthly completeness checks

• At the end of each month, compile:
  • Total CCM minutes logged per patient.
  • Add-on codes justified (≥40 minutes = CPT 99490 + CPT 99439).
  • Changes to care plan.
  • Unresolved tasks carried forward.
• Keep this in one place, ready for payer or CMS audit.
  

5. How Lara Health helps you stay audit-ready

Manually tracking minutes, supervision notes, and time allocation across AWV, CCM, RPM, and BHI is a recipe for errors. Lara Health’s platform builds compliance into the workflow:

• Automated time capture: Minutes are tracked in real time as staff log calls, outreach, and reviews.
• Service-line tagging: Each activity is tagged to CCM, RPM, BHI, or TCM, ensuring minutes aren’t double-counted.
• Consent logging: Patient consent for CCM is prompted, documented, and stored for annual renewal.
• Audit-ready records: At month’s end, Lara Health generates an itemized report of CCM and AWV activity, with time summaries, care-plan updates, and staff attribution - ready to share in the event of audit or denial.
• Dashboards: Leadership can monitor compliance, revenue capture, and staff performance at a glance.

Bottom line: Time attribution is the guardrail that makes AWV and CCM integration safe and profitable. With clear rules and automated compliance tools like Lara Health, practices can expand these programs confidently, knowing their documentation will stand up to scrutiny and their revenue will be secure.

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Putting it together: the patient journey (first 90 days)

When AWVs and CCM are stitched together properly, the patient experience feels continuous and supportive rather than fragmented. Here’s how the first 90 days can look when the handoff is intentional.

Day 0 - Annual Wellness Visit (AWV)

• The patient completes their AWV and leaves with a clear prevention plan.
• Clinician highlights top 2-3 chronic priorities (e.g., lower BP, complete overdue retinal exam, address fall risk).
• MA or nurse explains CCM, captures consent, and schedules the first monthly CCM call before the patient leaves.
• Orders for labs, referrals, and vaccines are entered; reminders are linked to the patient’s chart.
  

Day 7 - First CCM touchpoint

• The CCM nurse calls to confirm that the patient received and understands their personalized prevention plan.
• Home monitoring devices are shipped or set up; technique is reviewed.
• Referrals (e.g., colonoscopy, eye exam) are confirmed on the calendar.
• Barriers such as transport, cost, or pharmacy issues are logged and addressed.
  

Day 30 - Second CCM touchpoint

• Review of home BP or glucose readings; escalate if averages remain out of range.
• Confirm that preventive services (labs, imaging, vaccinations) are on track or completed.
• Medication adherence and side effects reviewed.
• Any open items from AWV are moved into the “completed” column or rescheduled.
  

Day 60 - Third CCM touchpoint

• CCM nurse checks referral follow-through, did the patient complete the ordered eye exam or PT sessions?
• Education is reinforced (fall prevention, nutrition, inhaler technique).
• Escalations are routed to the clinician when indicated.
• The care plan is updated to reflect new labs or specialist recommendations.
  

Day 90 - Mini-review and loop-back to clinician

• CCM nurse summarizes progress for the clinician: which AWV priorities were met, what’s still pending, and any new risks identified.
• Goals for the next quarter are set (e.g., HbA1c recheck in 3 months, colonoscopy scheduled for next month).
• The patient is reminded of their next AWV due date and understands the ongoing cadence of monthly support.

How Lara Health makes this journey easy

Running this playbook manually can be cumbersome, but Lara Health makes the AWV-CCM continuum simple, efficient, and audit-ready.

• Patient identification: Lara Health automatically surfaces patients eligible for AWVs and CCM (≥2 chronic conditions) from your EHR, ensuring no one falls through the cracks.
• Enrollment made easy: Consent prompts are built into workflows, so staff can enroll patients in CCM at the time of the AWV with a few clicks.
• Reliable scheduling: Monthly CCM calls and annual AWVs are scheduled automatically, with reminders for patients and dashboards for staff to track completion.
• Program flexibility: Whether a clinic has an in-house team or needs additional support, Lara Health adapts. Practices can leverage their own nurses and MAs or tap into Lara Health’s US-based, registered, licensed, highly experienced virtual care managers who slot seamlessly into existing workflows.
• Integrated dashboards: Care plans, minutes logged, referrals, preventive orders, and AWV completion rates all flow into a single view. Managers see at a glance what’s been done, what’s overdue, and how performance ties to quality and financial outcomes.
• Audit-ready documentation: Every activity is logged with the correct service-line tag (AWV, CCM, RPM, BHI), ensuring time attribution is clean and defensible.

Bottom line: The first 90 days after an AWV set the tone for whether a prevention plan turns into action. With Lara Health’s platform and care team support, practices can reliably identify eligible patients, enroll them in CCM, execute the plan with monthly touchpoints, and keep AWVs on schedule year after year, without straining staff capacity.

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Conclusion

Annual Wellness Visits (AWVs) and Chronic Care Management (CCM) are not just two separate benefits, they are complementary gears in a single engine. The AWV defines the priorities for prevention and chronic disease care; CCM makes sure those priorities are acted on, tracked, and refined month after month. Together, they transform patient care from episodic to continuous, from reactive to proactive.

But success doesn’t happen automatically. To make AWVs and CCM run seamlessly, you need:

• Systematic patient identification so no one eligible is missed.
• Smooth enrollment workflows so patients are brought into CCM the moment an AWV uncovers chronic needs.
• Reliable monthly execution with staff capacity to call, follow up, and close gaps.
• Audit-ready documentation to protect your revenue and prove compliance.
  

That’s exactly where Lara Health steps in. Our platform and team make it effortless to:

• Identify and enroll eligible patients during the AWV.
• Automate scheduling of monthly CCM touches and annual AWVs.
• Track minutes, tasks, and preventive orders with clean attribution across CCM, RPM, BHI, and TCM.
• Scale your program with our US-based, licensed, highly experienced virtual care managers, who plug directly into your workflows if your in-house team is stretched thin.
• Deliver dashboards and reports that tie patient progress directly to quality metrics and financial performance.
  

With Lara Health, AWVs don’t just generate a prevention plan, they become the starting line for a year-long continuum of care, revenue, and measurable results. If your practice wants to unlock the full potential of AWVs and CCM, while protecting staff bandwidth and ensuring compliance, the next step is simple: Book a demo with Lara Health and see how we can turn annual visits into year-round outcomes and revenue.

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FAQ

Can Annual Wellness Visits (AWVs) and Chronic Care Management (CCM) be billed together?

Yes. AWVs (G0438/G0439) and CCM (99490/99439) are distinct services. The AWV is billed once every 12 months, while CCM is billed monthly for eligible patients. Both can be reimbursed when requirements are met and time is not double-counted.

How does an AWV help identify patients for CCM?

The AWV includes a comprehensive review of preventive and chronic care needs. Patients with two or more chronic conditions (such as diabetes, hypertension, COPD, or CKD) are flagged as eligible for CCM during the visit, making the AWV the ideal entry point for enrollment.

What are the requirements for CCM eligibility?

To qualify for CCM, a patient must have at least two chronic conditions expected to last 12 months or longer, with a risk of functional decline, exacerbation, or death. Documented patient consent is also required before CCM services can begin.

What role does CCM play after the AWV?

The AWV generates a prevention plan; CCM operationalizes it. Each month, the CCM team follows up with the patient, tracks progress on labs, screenings, or home monitoring, coordinates with specialists, and escalates concerns to the clinician as needed.

Is time spent on CCM, RPM, or BHI activities interchangeable?

No. Minutes may not be double-counted. For example, reviewing device data belongs to RPM, medication coaching belongs to CCM, and PHQ-9 counseling belongs to BHI. Each service line must be tracked separately for compliance.

What revenue potential exists by combining AWVs and CCM?

AWVs reimburse around $200 per visit (locality-dependent), and CCM generates $62-$80 per patient per month. Together, these programs can produce hundreds of dollars per patient annually in sustainable revenue, while also driving quality incentive bonuses.

Can CCM support preventive care identified during an AWV?

Yes. Monthly CCM calls are a perfect mechanism to remind patients about overdue screenings, vaccinations, or follow-ups surfaced in the AWV. CCM keeps preventive tasks from falling through the cracks.

How does Lara Health support practices running AWVs and CCM?

Lara Health’s platform automates patient identification, consent, scheduling, and documentation for AWVs and CCM. Practices can use their in-house staff or leverage Lara Health’s US-based, licensed, highly experienced care managers to run CCM. The result is reliable enrollment, consistent follow-up, audit-ready records, and a direct lift in both outcomes and revenue.

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Other articles you might find interesting

Annual Wellness Visits and Preventive Care: How AWVs Help Close Care Gaps

Annual Wellness Visit (AWV) 101: What It Is and Why It’s Important

Why Chronic Care Management is a Game-Changer for Patient Outcomes

Integrating CCM and RPM for Better Outcomes

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Sources

CMS - Medicare Wellness Visits (AWV) overview and frequency.

CGS Medicare - AWV Fact Sheet.

CMS - Chronic Care Management.

CMS - CCM FAQ and TCM booklet.