Pre-visit planning for value-based care: what to prepare

By Jay Chowdappa, MD, co-founder and CEO, Zynix AI · Updated October 9, 2026

Key takeaways

Pre-visit planning in value-based care is the work done before an appointment so the visit closes what it needs to: open quality gaps, chronic conditions to reassess, labs and screenings due, annual wellness visit items, a current medication list and any recent ED visit or discharge. Staff prepare it; the clinician assesses, documents and decides.

Give each item a named owner and a known data source; an item without an owner does not get prepared.
Run two lists: scheduled patients need a summary in front of the clinician, and unscheduled patients with open gaps need outreach and a booked visit first.
Prepare fully for wellness visits, recent discharges and conditions not yet assessed this year, and give other visits a quick check.
In Medicare Advantage, CMS requires diagnoses submitted for risk adjustment to be documented in the medical record as a result of a face-to-face visit, so a gap list alone closes nothing.
Track visits prepared out of visits seen, and gaps addressed at the visit, against your own baseline; avoid targets that reward coding volume.

If you run an ACO, an MSO or a physician group, you probably already have a list of open gaps. The list is rarely the hard part. The visit is where a gap gets closed or carried into next month, and what happens in the room depends on what was ready before the patient walked in.

What is pre-visit planning in value-based care?

Pre-visit planning is the routine of getting everything a visit needs ready before the patient is in the room, so the clinician spends the visit on the patient rather than the chart. In value-based care, the routine also reaches patients who are not on the schedule yet.

An AMA summary of its STEPS Forward pre-visit planning module lists 10 steps in three phases: during the current visit, before the next visit and during the next visit. The timing table below follows that sequence.

The evidence is mostly about process. An environmental scan in the Annals of Family Medicine found pre-visit planning described as a team process, typically with a medical assistant or nurse reviewing the chart, identifying care gaps and creating orders for the physician to sign. Most of the published implementations it found (21 of 26) focused on closing care gaps, none described all 10 AMA steps, and demonstrated impact was mostly limited to process outcomes. Treat pre-visit planning as sound practice guidance, not as a proven route to better patient outcomes.

What changes under risk contracts is the scope. A fee-for-service clinic prepares the patients on tomorrow’s schedule. An organization accountable for an attributed population also has to find the patients with open gaps and no visit booked, and get them onto the schedule.

The pre-visit planning checklist: what to prepare and who owns it

Check eight items for every scheduled visit and prepare the ones that apply. Each needs a named owner and a known data source, and the result should reach the clinician before the visit starts, not after rooming.

Item	Why it matters	Who prepares	Where the data comes from
Open quality gaps	Quality measures close only when the service or result is documented, not when the patient is reminded.	Quality coordinator or medical assistant	Claims, EHR, lab results, payer gap lists
Chronic conditions to reassess this year	In Medicare Advantage, a condition counts for risk adjustment only when it is assessed and documented at a visit (see the risk adjustment section).	HCC or quality team prepares the prompt; the treating clinician assesses	Prior claims, problem list, medication list, labs
Labs and screenings due	Results that are back before the visit can be discussed and acted on at the visit.	Nurse or medical assistant under the practice’s ordering rules; the clinician signs orders	EHR orders, lab results
Annual wellness visit elements	Wellness visits only. The health risk assessment can be done before the visit, and CMS asks practices to encourage patients to bring records, family history, a full medication and supplement list, and a list of their providers and suppliers.	Front desk or medical assistant sends the assessment; the patient completes it	Medicare enrollment, claims history of earlier wellness visits and the Welcome to Medicare visit
Medications	The full list includes supplements. After a discharge from a hospital inpatient stay, observation, partial hospitalization or a skilled nursing facility, transitional care management (TCM) requires medication reconciliation on or before the face-to-face visit date.	Nurse or pharmacist prepares; the clinician decides any change	EHR medication list, pharmacy fills, discharge documents
Recent ED visits, admissions and discharges	Interval events change the agenda. After those discharges, TCM needs an interactive contact within 2 business days and a face-to-face visit within 7 or 14 calendar days.	Care manager or RN prepares; licensed clinical staff make the TCM interactive contact	Hospital ADT notifications, discharge documents, claims
Outside notes and results	Notes from interval care by specialists and hospitals belong in the record before the visit.	Medical assistant or nurse	Referral notes, C-CDA documents, faxed records
The patient’s own agenda and barriers	A pre-visit call or questionnaire surfaces what the patient wants to cover, and barriers such as transport or cost.	Medical assistant, nurse or coordinator	The patient

These sources rarely sit in one system. The scheduled list starts from each practice’s appointment schedule, usually a feed or a daily export from its EHR or practice-management system. Claims show services billed elsewhere, the EHR shows what your practice documented, and ADT notifications show admissions and discharges from the hospitals that send them. A registry can bring them together, and so can population intelligence that shows the clinician open gaps, risk drivers and care-plan tasks at the visit.

In a network of practices on different EHRs, the central team needs each practice’s schedule and an agreed place, such as a worklist or a huddle sheet, where the clinic sees the summary before the session starts.

Prepare the visits that need it most

Not every visit needs every item. Programs in the Annals scan commonly focused on a high-risk group, such as patients with diabetes, or on specific quality measures. A simple tiering works:

Full preparation for wellness visits, visits after a recent discharge or ED visit, patients with chronic conditions not yet assessed this year, and complex patients.
A quick check for every other visit: open gaps, results that are back and any interval event.

What the clinician summary should show

The summary is what pre-visit planning delivers: one screen the clinician reads before the patient is roomed. It should show:

What needs attention at this visit, in that order, not grouped by data source.
Evidence for each listed condition: its source and date (a claim, a lab result, a medication fill or a specialist note) and when it was last documented.
What would close each quality gap, and whether it was already done elsewhere.
Interval events since the last visit: ED visits, admissions, discharges, new prescriptions and outside results.
The patient’s own agenda, from the pre-visit call or questionnaire.
A place to mark each item addressed, ruled out or deferred, so follow-up and measurement use the same record.

Put it where the clinician already looks before rooming, such as the schedule view or the huddle sheet. Showing the evidence also lets a compliance reviewer see why each condition was raised.

Scheduled and unscheduled patients need different work

Run two lists. Scheduled patients need the checklist and the summary in front of their clinician. Unscheduled patients, meaning attributed patients with open gaps and no visit booked, need outreach and a booked visit first.

The scheduled list belongs to the clinic: the nurse or medical assistant who preps each session. The unscheduled list needs its own owner, usually a central coordinator or outreach team, or it turns into a report nobody works. Work it by the time left to close each gap and by how many open gaps or conditions each patient has. A few rules keep the outreach clean:

Check before you call. Compare each gap against claims, clinical and lab data first, so patients who already had the service elsewhere are not invited for it again.
Honor opt-outs. A patient who declines a service or opts out should come off automated contact in line with your consent and opt-out policy.
Send clinical reasons to a provider. When a patient gives a clinical reason for not having a service, record it and route it to a provider, who confirms or rejects the exclusion. Outreach staff do not decide exclusions.
Book with preparation attached. Book with the patient’s own practice where you can, and send instructions with the booking: what to bring, whether labs come first, and how to complete the health risk assessment. A telehealth visit meant to assess chronic conditions should be video, not audio-only.
Close on the visit, not the call. A booked appointment is progress. The gap closes when the service or result is documented.

Staff, a call center or voice and text agents can run the outreach. Whoever runs it should hand clinical questions to a clinician by rule.

When to prepare each item

Preparation starts at the end of the previous visit and finishes at the huddle on the day. The sequence matters more than an exact number of days: book and order first, gather and confirm next, prepare the chart last, and hand off on the day.

When	What happens	Who
At the end of the previous visit	Book the next visit, note the interval and any labs needed first, and arrange labs to be drawn before it.	Clinician, medical assistant, front desk
Once the visit is booked	Review open gaps and conditions; send the health risk assessment for wellness visits; time lab draws so results are back; send reminders; call complex patients for medication reconciliation and agenda-setting.	Coordinator, nurse or medical assistant
The day before or just prior	Prepare the chart and the summary: the last note, interval care, results in the record and the care-gap checklist.	Nurse or medical assistant
The day of the visit	Huddle; check-in questionnaire if not already done; handoff to the physician after rooming.	Care team
All year	Outreach to unscheduled patients, so gap work does not pile up in the last quarter.	Coordinator or outreach team

Illustrative example: a patient with type 2 diabetes is booked for her annual wellness visit. A week before the visit, she is seen in the ED after a fall.

When the visit is booked. The coordinator sees an open diabetic eye exam and an HbA1c test due, sends the health risk assessment with a request to bring her medication and supplement list, and asks the nurse to arrange the lab draw under the practice’s ordering rules.
When the ED notification arrives. The ED visit comes in as a hospital ADT notification, so the nurse calls her, asks how she is doing and notes her questions about a prescription started in the ED.
The day before. The medical assistant pulls the ED note into the record and puts the fall, the new prescription and the open items on the summary for the huddle.
At the visit. The physician reviews the fall as part of the wellness visit’s safety review and decides whether managing her diabetes, the new prescription and the fall is a significant, separately identifiable E/M service reported with modifier 25, or needs its own visit. Any medication change is the physician’s decision.

What to prepare for an annual wellness visit

The annual wellness visit (AWV) is a health risk assessment plus personalized prevention plan services, not a routine physical, and much of it can be prepared before the patient arrives.

CMS’s AWV guidance sets the minimum content of the health risk assessment: demographic data, a health status self-assessment, psychosocial and behavioral risks, and both basic and instrumental activities of daily living, such as managing medications. Under 42 CFR 410.15, the patient can complete it independently, or a health professional can administer it, before or as part of the visit. Offer it in the patient’s language, with phone help for those who need it; the regulation expects the assessment to fit patients’ communication and health-literacy needs.

AWV element	What to have ready
Health risk assessment	Sent before the visit; completed by the patient or with staff help; answers flagged for the clinician
Medical and family history, including medications, supplements and other substances	The patient’s records, family history and full medication and supplement list, including any opioid prescriptions for the opioid review
Current providers and suppliers	The patient’s list, including community-based providers and behavioral health specialists
Cognitive impairment check	Any concerns from family or caregivers, noted in advance
Review of depression risk factors	A standardized screening tool chosen in advance
Functional ability and safety, including fall risk	Relevant assessment answers and any recent falls or ED visits
Written screening schedule	Screening history from claims and the record, so the schedule reflects what is already done
List of risk factors and conditions	Problem list and open gaps, with interventions recommended or underway

Measurements, advance care planning (at the patient’s discretion), substance use disorder screening, health advice and referrals, and the optional physical activity and nutrition assessment happen in the room. Subsequent visits update most of these elements rather than starting over.

Two decisions belong at booking. Eligibility: Medicare.gov says Medicare covers a wellness visit once every 12 months, and the first can’t take place within 12 months of Part B enrollment or the Welcome to Medicare preventive visit. Visit type: Medicare.gov tells patients to schedule a separate appointment for specific health concerns, so the wellness visit stays focused on prevention. When a significant, separately identifiable, medically necessary E/M service does happen at the same visit, CMS may pay for it, reported with modifier 25. Coinsurance and the Part B deductible may apply to additional tests or services at that visit that the wellness benefit does not cover, so tell patients up front. Codes and eligibility are covered in more detail in our guide to improving AWV completion rates.

Why risk adjustment depends on the visit itself

In Medicare Advantage, Chapter 7 of CMS’s Medicare Managed Care Manual requires diagnoses submitted for risk adjustment to be documented in the medical record as a result of a face-to-face visit. A list of suspected conditions closes nothing until a clinician assesses the patient and documents what is clinically present.

Each base year starts fresh. CMS describes its CMS-HCC (hierarchical condition category) model as prospective: it uses diagnoses from a base year to predict Medicare costs for the following year. A chronic condition counts toward the following year’s risk score only if it is assessed and documented during the current year.
The source has to qualify. The acceptable sources are hospital inpatient facilities, hospital outpatient facilities and physicians. For physician data, the manual’s list of acceptable specialty types includes nurse practitioners and physician assistants.
Telehealth needs video; chart review needs an encounter. CMS guidance from 2021 says telehealth diagnoses meet the face-to-face requirement when the visit uses interactive audio and video together. For CY 2027 risk scores, CMS is excluding diagnoses from audio-only encounters. It is also excluding diagnoses from unlinked chart review records (diagnoses not tied to a specific encounter), except for beneficiaries who switch from one MA organization to another.

These are Medicare Advantage rules. Shared Savings Program ACOs and other risk contracts are governed by their own program and contract terms, so check those before applying Medicare Advantage rules to them. Whatever the contract, an HCC recapture workflow for ACOs should end at the documented visit, not at the outreach call.

The clinician’s part: assess, document, decide

Preparation tells the clinician what to consider. The clinician decides what is clinically present, documents it or rules it out, and decides on orders, referrals and medication changes. Ruling a condition out is a valid result of the visit, not a failure. No staff member or software should decide a diagnosis for the clinician, and nothing should be submitted that the clinician has not documented.

Staff and tools prepare	The clinician decides
Open gaps, listed conditions, results and outside notes, assembled before the visit	Whether each listed condition is present, and what to document or rule out
The health risk assessment, reminders, lab appointments and visit bookings	Which labs, screenings and referrals to order
The medication list, prepared for review	Whether to start, stop or change a medication
Flags for recent discharges and ED visits	What the interval event means for the plan of care
A patient’s stated reason for declining a service, recorded	Whether a clinical exclusion applies
A draft note, where ambient documentation is used	Whether to approve the note, after review and edits

Coding follows the documentation under ICD-10-CM guidelines, not the other way round. If you use ambient documentation, the draft note stays a draft until the physician reviews and approves it, and nothing from a pre-visit prompt or a draft note should reach a claim without that review.

Where pre-visit planning breaks down

Pre-visit planning usually fails on ownership and timing rather than on knowing what to do. The Annals scan lists the barriers most often described in the literature and in its interviews: lack of time, staff turnover or shortages, the need to educate patients and clinicians, and the difficulty of changing established workflows. It adds that the lack of reimbursement for pre-visit planning will remain a key barrier until value-based care is further along.

What you see	What to change
Summaries arrive after rooming, or where the clinician does not look.	Set a cutoff, such as the morning huddle, and deliver the summary where the clinician already looks.
Labs are ordered but not drawn, so results come back after the patient leaves.	Order at the previous visit and book the draw when the visit is booked.
No item has a named owner, so everything belongs to “the team”.	Name an owner for each checklist item at each practice.
Discharges are missed: a hospital does not send ADT notifications, or they land in an inbox nobody watches.	Confirm which hospitals send notifications to each practice, and name who works them each day.
The wellness visit fills with problem-oriented care.	Decide the visit type at booking, and plan a separate visit or a separately reported service when needed.
Follow-ups from the prevention plan, such as referrals and screenings, have no owner after the visit.	Give each open item an owner before the patient leaves.

The ADT point deserves a note. CMS’s conditions of participation require hospitals whose electronic systems conform to the content exchange standard to send notifications at ED registration, inpatient admission, and ED or inpatient discharge or transfer, and to make a reasonable effort to ensure those notifications go to the patient’s established primary care practitioner or practice group. That is a floor, not a guarantee that every event reaches each of your practices.

What to measure

Track a handful of counts and rates against your own baseline, by practice and by clinician, and avoid any target that rewards coding volume.

Measure	What it tells you
Scheduled visits prepared before the visit, out of visits seen	Whether preparation keeps up with the schedule
Listed gaps addressed at the visit: documented, completed or ruled out	Whether the summary reaches the clinician in time to be used
Listed conditions the clinician addressed	Whether prompts are reviewed, without implying that any should be coded
Labs resulted before the visit	Whether ordering at the previous visit and lab timing work
Health risk assessments completed before the AWV	Whether the assessment has moved out of the exam room
Unscheduled patients reached, booked and seen	Whether the second list is being worked
Gaps still open after the visit, with a named owner	Whether follow-ups have someone accountable

Report “addressed” rather than “captured”. A condition the clinician ruled out is a correct result, and a measure that counts only conditions documented as present pushes the wrong way.

Where Zynix fits

Zynix prepares the visit and brings in unscheduled patients; clinicians make every clinical decision.

Gaps in front of the clinician. Clinics see the open gaps for each scheduled patient before the visit, as prompts for the clinician to assess. ZynScribe’s pre-visit review shows the same gaps, and its note stays a draft until a physician reviews and approves it.
Visit readiness with an owner. On the Embedded Care Management Platform, a visit-readiness care plan for patients with diabetes, CHF or COPD has reminders, pre-visit labs and open gaps prepared for the care team, and every task has an owner and a due date, with missed steps escalated by rule.
Outreach to unscheduled patients. Voice and text agents invite each patient, book the visit, send two-way reminders, confirm or reschedule, and track the visit to completion. Scheduling conflicts and patient questions go to a care coordinator. Across the platform, symptom questions go to the on-call clinician by rule, and callers describing an emergency are told to call 911.

Frequently asked questions

What should a pre-visit planning checklist include?

A pre-visit planning checklist covers eight items: open quality gaps, chronic conditions to reassess this year, labs and screenings due, annual wellness visit elements, the full medication list, recent ED visits and discharges, outside notes and results, and the patient’s own agenda. Each item needs a named owner and a known data source, and not every item applies to every visit.

Who on the care team should do pre-visit planning?

In the AMA’s guidance, a nurse or medical assistant prepares the chart the day before or just before the visit. A coordinator or outreach team owns unscheduled patients, care managers or nurses follow up on recent discharges, and licensed clinical staff make the TCM interactive contact. The treating clinician assesses each condition, documents it or rules it out, and decides on orders and medication changes.

What should a pre-visit summary show the clinician?

One screen, ordered by what needs attention at this visit. Each listed condition shows the evidence behind it, with its source and date, and when it was last documented. Each open quality gap shows what would close it. The summary also lists interval events since the last visit and the patient’s own agenda, and gives the clinician a place to mark each item addressed, ruled out or deferred.

Can patients complete the health risk assessment before the annual wellness visit?

Yes. Under 42 CFR 410.15, the patient can complete the health risk assessment independently, or a health professional can administer it, before or as part of the visit, and CMS says the assessment can be updated before or during the AWV. Sending it with the appointment confirmation, and offering help by phone, keeps exam-room time for the prevention plan and the clinician’s review.

Does a condition on a pre-visit summary count for risk adjustment?

No. A pre-visit summary is a prompt, and software should not decide what is clinically present. In Medicare Advantage, CMS requires diagnoses submitted for risk adjustment to be documented in the medical record as a result of a face-to-face visit, from an acceptable source. A condition counts only if the treating clinician assesses and documents it; coding follows that documentation, and ruling a condition out is an equally valid result.

Source notes

CMS: Annual Wellness Visit. https://www.cms.gov/medicare/coverage/preventive-services/medicare-wellness-visits/annual-wellness-visit

eCFR: 42 CFR 410.15, Annual wellness visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-410/subpart-B/section-410.15

Medicare.gov: Yearly “Wellness” visits. https://www.medicare.gov/coverage/yearly-wellness-visits

CMS: Medicare Managed Care Manual, Chapter 7: Risk Adjustment (Rev. 118, September 2014). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c07.pdf

CMS: Applicability of diagnoses from telehealth services for risk adjustment, update (January 15, 2021). https://www.cms.gov/files/document/applicability-diagnoses-telehealth-services-risk-adjustment-update-1152021.pdf

CMS: 2027 Medicare Advantage and Part D Rate Announcement (fact sheet, April 6, 2026). https://www.cms.gov/newsroom/fact-sheets/2027-medicare-advantage-part-d-rate-announcement

CMS: Admission, Discharge, and Transfer Patient Event Notification Conditions of Participation (42 CFR 482.24(d), 482.61(f) and 485.638(d)). https://www.cms.gov/initiatives/burden-reduction/overview/interoperability/frequently-asked-questions/admission-discharge-transfer-patient-event-notification-conditions-participation-cop-42-cfr-482-24d

CMS Medicare Learning Network: Transitional Care Management Services (MLN908628, August 2025). https://www.cms.gov/files/document/mln908628-transitional-care-management-services.pdf

American Medical Association: 10 steps to pre-visit planning that can produce big savings (September 4, 2015). https://www.ama-assn.org/practice-management/scope-practice/10-steps-pre-visit-planning-can-produce-big-savings

Annals of Family Medicine: Holdsworth LM, Park C, Asch SM, Lin S. Technology-Enabled and Artificial Intelligence Support for Pre-Visit Planning in Ambulatory Care: Findings From an Environmental Scan. Ann Fam Med. 2021;19(5):419-426. https://pmc.ncbi.nlm.nih.gov/articles/PMC8437572/

About the author

Jay Chowdappa, MD is co-founder and CEO of Zynix AI. He is a physician, and ACOs led by him generated $300M+ in shared savings before he started Zynix AI to help care teams follow through on what their data already shows.

Preparing visits across your practices?

See how Zynix AI puts open gaps in front of clinicians before the visit and brings in unscheduled patients, with clinicians making every clinical decision.

Book a 30-min walkthrough →