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Education, trainings and manuals, regulations, news and insights, annual wellness visit (awv) documentation and coding.

A Medicare Annual Wellness Visit (AWV) is not a typical physical exam. Rather, it’s an opportunity to promote quality, proactive, cost-effective care. AWVs help you engage with your patients and increase revenue.

A physician, PA, NP, certified clinical nurse specialist or a medical professional under the direct supervision of a physician (including health educators, registered dietitians and other licensed practitioners) can perform AWVs.

AWV documentation

Document all diagnoses and conditions to accurately reflect severity of illness and risk of high-cost care.

An ICD-10 Z code is the first diagnosis code to list for wellness exams to ensure that member financial responsibility is $0.

• Z00.00 — encounter for general adult medical examination without abnormal findings
• Z00.01 — encounter for general adult medical examination with abnormal findings

The two CPT® codes used to report AWV services are:*

• G0438 — initial visit**
• G0439 — subsequent visit (no lifetime limits)

Additional services (lab, X-rays, etc.) ordered during an AWV may be applied toward the patient’s

deductible and/or be subject to coinsurance. Before performing additional services, discuss them

with the patient to verify that the patient understands their financial responsibilities.

More information

For additional information and education, contact us at  [email protected] .

*CPT® is a registered trademark of the American Medical Association.

**Code G0438 is for the first AWV only. The submission of G0438 for a beneficiary for which a claim code of G0438 has already been paid will result in a denial.

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How to avoid Medicare annual wellness visit denials

If you’re seeing a high number of denials for Medicare annual wellness visits (AWVs), you’re not alone. Identifying whether to code for an Initial Preventive Physical Exam (IPPE, or the “Welcome to Medicare” visit), an initial Medicare AWV, or a subsequent Medicare AWV can be tricky.

Common reasons for denial include the folllowing:

1. Billing a G0438 (initial Medicare AWV) or G0439 (subsequent Medicare AWV) when the patient has been enrolled in Medicare Part B for 12 months or less. This situation instead calls for billing G0402 (IPPE).

2. Billing for a Medicare AWV when the patient only has Medicare Part A . They must have Part B coverage as well.

3. Using the wrong primary diagnosis code. If the primary diagnosis code is problem-oriented (e.g., diabetes or hypertension), Medicare will most likely deny a claim for an AWV, because AWVs are “well visits.” Instead, list a well code (e.g., Z00.0X, “encounter for general adult exam”) as the primary diagnosis.

The IPPE also has a slightly different set of required components (e.g., advance care planning and visual acuity screening with documentation of results in the note) than the two types of AWVs (e.g., instrumental activity of daily living and assessment of cognitive function).

Here are some frequently asked questions to help you further navigate the world of AWV billing, as well as a side-by-side comparison of the three types of Medicare wellness visits.

Q - What is the difference between a Medicare AWV and a preventive visit?

A - Medicare AWVs consist of three specific visit types statutorily covered by Medicare with no co-pay or deductible. They are the IPPE (the “Welcome to Medicare” visit, G0402), the initial AWV (G0438), and the subsequent AWV (G0439). These visits do not require a comprehensive physical exam. Preventive visits (9938X and 9939X) are covered by commercial/managed care and Medicaid plans and require a comprehensive physical exam. They are also include no co-pay or deductible.

Q - Can a Medicare patient receive a preventive visit?

A - Yes, but traditional Medicare does not cover these visits (9938X and 9939X are statutorily prohibited), so patients with that coverage will have to pay 100% out-of-pocket. However, some Medicare Advantage plans cover both Medicare AWVs (G codes) and non-Medicare (commercial) preventive visits (9938X and 9939X). Medicare Advantage patients would need to check their plan benefits to find out if they have coverage for both.

Q - Is the IPPE the same as the initial AWV?

A - No, the IPPE is the Initial Preventive Physical Examination, also known as the "Welcome to Medicare" visit (G0402), while the initial AWV (G0438) is the patient’s first Medicare AWV following the IPPE. These are two different types of visits, and billing a G0438 when the patient was actually only eligible for a G0402 is a common cause of denials.

Q - What diagnosis code should I use to bill a Medicare wellness exam?

A - Use the Z00 family of codes.

Q - Do Medicare wellness visits need to be performed 365 days apart?

A - No. A Medicare wellness visit may be performed in the same calendar month (but different year) as the previous Medicare wellness visit. For example, if a patient had a Medicare AWV on June 30, 2020, then that patient is eligible again on June 1, 2021. If a patient had a Medicare AWV on June 1, 2020, then that patient is also eligible again on June 1, 2021. But if you bill a Medicare AWV for either patient on May 31, 2021, it will be denied, because it is in a different calendar month and too soon.

Q - Can I bill for a Medicare AWV and a commercial insurance preventive visit for the same patient in the same year?

A - Yes, you can do this if the patient has both as part of their covered benefits. Some patients have a commercial payer as their primary insurance and Medicare as their secondary.

Q - Can I perform Medicare wellness visits in skilled nursing facilities or as home visits?

A - Yes. Just make sure the place of service (POS) on the claim corresponds to the correct location.

Q - Can I perform a pap smear or pelvic exam during a Medicare AWV?

A - Yes, and they are both separately billable. Use code Q0091 for the screening pap smear in a Medicare patient. The pelvic exam must be combined with a breast exam and then billed together using G0101. Specific documentation components are required for the G0101.

Q - If a patient has a managed Medicare plan (non-traditional Medicare), can I still bill a G code (G0402, G0438, or G0439) for a wellness visit?

A - Yes. Traditional Medicare and all managed Medicare plans will accept the G codes for AWVs.

Q - Can I bill a routine office visit with a Medicare AWV?

A - When appropriate, a routine office visit (9920X and 9921X) may be billed with a Medicare AWV. Modifier -25 should be appended to the evaluation and management (E/M) code. Cost sharing will apply to the E/M service, though, just as it would without the Medicare AWV. Make sure patients are aware of this, as some may expect that all services provided on the same day as the Medicare AWV are covered at 100%.

Which type of Medicare AWV is this?

— Vinita Magoon, DO, JD, MBA, MPH, CMQ, Baylor Scott & White Health, Temple, Texas

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CPT Codes for Annual Wellness Visits

Annual Wellness Visits (AWV) are a type of preventive care for Medicare patients. There are many benefits to implementing this type of program, such as improving patient outcomes and filling in gaps in care. However, you must understand the CPT billing codes to ensure your claims are not denied and help drive revenue at your organization.

What Is the CPT Code for Annual Wellness Visits?

There are generally three codes associated with Annual Wellness Visits representing distinct phases in AWV programs:

• G0402:  This code applies to the Welcome to Medicare visit — also referred to as an Initial Preventive Physical Exam (IPPE). This exam is not an Annual Wellness Visit, but it is valuable for understanding the framework of an AWV program. A patient is only eligible for the first 12 months they are enrolled in Medicare. This one-time visit focuses on gaining a general understanding of health with a vision screen, vital measurements and other assessments. This code will be rejected if you apply it after the 12-month mark of enrollment.
• G0438:  After 12 months of being enrolled in Medicare, a patient becomes eligible for their initial Annual Wellness Visit. If a patient completes an IPPE, they are permitted to use this initial visit on the first day of the same calendar month the next year. When a patient does not complete IPPE, this code will apply any time after the 12-month mark.
• G0439:  You must use this code for all Annual Wellness Visits following the initial one. Among the AWV codes, this is the last one you will use, and it's the only one you will use repeatedly. 

There are various factors that define an Annual Wellness Visit. There are even differentiators between the initial AWV and all subsequent AWVs. However, you should first make sure you understand the difference between  an Annual Wellness Visit and an annual physical .

Requirements and Components for Billing AWV

The requirements and components for an AWV vary based on whether you apply G0438 or G0439.

The G0438 requirements include:

• A Health Risk Assessment (HRA)
• Medical and family history
• List of current providers involved in the patient's health
• Cognitive function assessment
• Blood pressure, height, weight, body mass index and other appropriate measurements
• Risk factors for depression
• Functional ability and safety assessment
• Screening schedule creation
• Risk factors and conditions
• Personalized health advice
• Advance Care Planning, if desired

The G0439 requirements involve updating all of the above factors. Additionally, the patient must not have received an Annual Wellness Visit in the last 12 months. 

Who Can Bill AWV Codes?

Unlike some other billing codes under CMS, Annual Wellness Visit billing does have some flexibility. Practices do not need to hire additional staff for their AWV program, and physicians do not have to be the only professionals involved. Rather than assigning specific tasks and responsibilities to different team members, CMS allows for AWV coverage with any of the following individuals:

• A physician
• A physician assistant (PA)
• A nurse practitioner (NP)
• A certified clinical nurse specialist (CNS)
• A medical professional or team under a physician's supervision, such as registered dieticians or health educators

AWV billing is also not limited to primary care providers. Select specialty practices can bill for AWVs, such as neurology and cardiology. Regardless of who bills the AWV with CMS, a person is only permitted to receive one AWV per year. For instance, a cardiologist cannot bill for an AWV two months after a primary care provider did — the claim will be denied.

It's not unusual for Medicare patients to see one or more specialists, which can lead to AWV billing conflict. Having a real-time system in place to check eligibility can be a major advantage to all care providers.

Additional AWV Codes

At ChartSpan, we provide eligibility checks for G0438 and G0439 — the core codes for Annual Wellness Visits. However, some AWVs may involve additional codes depending on a patient's needs. Examples of additional codes include:

• 99497:  Advance Care Planning is an optional element of an AWV, and it includes a discussion about advance directives and other care wishes. The co-pay is waived when it's billed on the same day as an AWV.
• G0442 and G0443:  These codes must be used together, and they apply to an Annual Alcohol Screening and 15-minute alcohol counseling session, respectively.
• G0477:  This code is for a 15-minute obesity counseling session and it can be billed with IPPE or an AWV. 
• G0153 and G0154:  When an AWV takes longer than the typical service, these codes can be added for prolonged preventive services. The codes represent an extra 30 minutes and an additional 60 minutes, respectively.

Talking About AWV With Medicare Patients

Introducing an AWV program at your practice can help you shift from the  Fee-for-Service model to Value-Based Care (VBC) . AWV programs contribute to the VBC model because your practice receives payments based on patient health outcomes. Since AWVs are a form of preventive care, you can identify risk factors in your Medicare patients and take action on those factors to improve patient outcomes and close gaps in care.

The VBC model offers benefits to all parties involved in the healthcare system. Patients spend less to maintain their health, and providers can increase patient satisfaction to keep them coming back for appointments. While practices have to spend more time on preventive care, the time saved on chronic disease management is meaningful. Payers then reduce risks and have stronger cost controls. 

When discussing the Annual Wellness Visit with your patients, remind them that this type of preventive care reduces the risk of more severe disease and can improve their quality of life in the long term. 

Grow Your Medicare AWV Program With ChartSpan

Annual Wellness Visits offer advantages at many stages in the healthcare system, but they still come with challenges. The greatest hurdle your practice faces is patient eligibility. With specialists and primary care providers capable of billing for these visits, a patient may have already had an AWV without you knowing. Providing AWV services and being denied can diminish the value of the program itself.

At ChartSpan, we have a software solution that supports eligibility checks for your AWV program.  RapidAWV™  starts by identifying eligible Medicare patients as they come in for their regularly scheduled appointments. From there, the system checks the HIPAA Eligibility Transaction System (HETS) to determine if a patient has had an AWV with any other provider.

This process allows providers to bill for an AWV when they can guarantee reimbursement rather than being denied following a claim. With our team supporting this function through patient engagement and interaction, your overall approach to billing and care becomes more efficient. Improve patient outcomes, close gaps in care and introduce a VBC model with ease. 

Learn more about ChartSpan  or  contact us  to get started with our software.

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Medicare’s Annual Wellness Visit (AWV)

The Medicare Annual Wellness Visit (AWV) is a yearly appointment with a health professional to identify health risks and help reduce them and to create or update a personalized prevention plan. During a Medicare AWV, health professionals should also review any current opioid prescriptions, detect any cognitive impairment, and establish or update medical and family history.

Coding and Billing a Medicare AWV

G0438: Annual wellness visit, includes a personalized prevention plan of service (PPS), initial visit

G0439: Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit

G0468: Federally qualified health center (FQHC) visit, IPPE, or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving IPPE or AWV

Diagnosis code V70.0; Initial Annual Wellness Visit G0438; Subsequent Annual Wellness Visit G0439

Medicare will pay a physician for an AWV service and a medically necessary service, e.g. a mid-level established office visit, Current Procedural Terminology (CPT) code 99213, furnished during a single beneficiary encounter. It is important that the elements of the AWV not be replicated in the medically necessary service. Physicians must append modifier -25 (significant, separately identifiable service) to the medically necessary E/M service, e.g. 99213-25, to be paid for both services.

For example, for the patient who comes in for his Annual Wellness Visit and complains of tendonitis would be billed as follows: CPT ICD9, G0438 V70.0, 99212-25 726.90 (tendonitis)

ACP Tools for the Annual Wellness Visit

The following forms and templates can be customized for use in your practice:

• Practice Checklist
• Patient Letter and Checklist
• Health Risk Assessment :
• View a paper version
• View an electronic version from HowsYourHealth.org
• Women's Prevention Plan
• Men's Prevention Plan
• Adult Health Maintenance Form
• Advanced Care Planning

Patient Handouts

• Patient FACTS

For more details about how to bill these codes, see Module 9 of Coding for Clinicians.

Medicare Wellness Visits Back to MLN Print November 2023 Updates

What’s Changed?

• Added information about monthly chronic pain management and treatment services
• Added information about checking for cognitive impairment during annual wellness visits
• Added information about Social Determinants of Health Risk Assessments as an optional element of annual wellness visits

Quick Start

The Annual Wellness Visits video helps you understand these exams, as well as their purpose and claim submission requirements.

Medicare Physical Exam Coverage

Initial Preventive Physical Exam (IPPE)

Review of medical and social health history and preventive services education.

✔ New Medicare patients within 12 months of starting Part B coverage

✔ Patients pay nothing (if provider accepts assignment)

Annual Wellness Visit (AWV)

Visit to develop or update a personalized prevention plan and perform a health risk assessment.

✔ Covered once every 12 months

Routine Physical Exam

Exam performed without relationship to treatment or diagnosis of a specific illness, symptom, complaint, or injury.

✘ Medicare doesn’t cover a routine physical

✘ Patients pay 100% out-of-pocket

Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health :

• Health Equity Technical Assistance Program
• Disparities Impact Statement

Communication Avoids Confusion

As a health care provider, you may recommend that patients get services more often than we cover or that we don’t cover. If this happens, help patients understand they may have to pay some or all costs. Communication is key to ensuring patients understand why you’re recommending certain services and whether we cover them.

Initial Preventive Physical Exam

The initial preventive physical exam (IPPE), also known as the “Welcome to Medicare” preventive visit, promotes good health through disease prevention and detection. We pay for 1 IPPE per lifetime if it’s provided within the first 12 months after the patient’s Part B coverage starts.

1. Review the patient’s medical and social history

At a minimum, collect this information:

• Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments)
• Current medications, supplements, and other substances the person may be using
• Family history (review the patient’s family and medical events, including hereditary conditions that place them at increased risk)
• Physical activities
• Social activities and engagement
• Alcohol, tobacco, and illegal drug use history

Learn information about Medicare’s substance use disorder (SUD) services coverage .

2. Review the patient’s potential depression risk factors

Depression risk factors include:

• Current or past experiences with depression
• Other mood disorders

Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. APA’s Depression Assessment Instruments has more information.

3. Review the patient’s functional ability and safety level

Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the patient’s:

• Ability to perform activities of daily living (ADLs)
• Hearing impairment
• Home and community safety, including driving when appropriate

Medicare offers cognitive assessment and care plan services for patients who show signs of impairment.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), blood pressure, balance, and gait
• Visual acuity screen
• Other factors deemed appropriate based on medical and social history and current clinical standards

5. End-of-life planning, upon patient agreement

End-of-life planning is verbal or written information you (their physician or practitioner) can offer the patient about:

• Their ability to prepare an advance directive in case an injury or illness prevents them from making their own health care decisions
• If you agree to follow their advance directive
• This includes psychiatric advance directives

6. Review current opioid prescriptions

For a patient with a current opioid prescription:

• Review any potential opioid use disorder (OUD) risk factors
• Evaluate their pain severity and current treatment plan
• Provide information about non-opiod treatment options
• Refer to a specialist, as appropriate

The HHS Pain Management Best Practices Inter-Agency Task Force Report has more information. Medicare now covers monthly chronic pain management and treatment services .

7. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them to treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

8. Educate, counsel, and refer based on previous components

Based on the results of the review and evaluation services from the previous components, provide the patient with appropriate education, counseling, and referrals.

9. Educate, counsel, and refer for other preventive services

Include a brief written plan, like a checklist, for the patient to get:

• A once-in-a-lifetime screening electrocardiogram (ECG), as appropriate
• Appropriate screenings and other covered preventive services

Use these HCPCS codes to file IPPE and ECG screening claims:

Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment

Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv

* Section 60.2 of the Medicare Claims Processing Manual, Chapter 9 has more information on how to bill HCPCS code G0468.

Report a diagnosis code when submitting IPPE claims. We don’t require you to use a specific IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an IPPE when performed by a:

• Physician (doctor of medicine or osteopathy)
• Qualified non-physician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist)

When you provide an IPPE and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

CPT only copyright 2022 American Medical Association. All rights reserved.

IPPE Resources

• 42 CFR 410.16
• Section 30.6.1.1 of the Medicare Claims Processing Manual, Chapter 12
• Section 80 of the Medicare Claims Processing Manual, Chapter 18
• U.S. Preventive Services Task Force Recommendations

No. The IPPE isn’t a routine physical that some patients may get periodically from their physician or other qualified non-physician practitioner (NPP). The IPPE is an introduction to Medicare and covered benefits, and it focuses on health promotion, disease prevention, and detection to help patients stay well. We encourage providers to inform patients about the AWV during their IPPE. The Social Security Act explicitly prohibits Medicare coverage of routine physical exams.

No. The IPPE and AWV don’t include clinical lab tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.

No. We waive the coinsurance, copayment, and Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening electrocardiogram (ECG) (HCPCS codes G0403, G0404, or G0405).

A patient who hasn’t had an IPPE and whose Part B enrollment began in 2023 can get an IPPE in 2024 if it’s within 12 months of the patient’s Part B enrollment effective date.

We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, find your MAC’s website .

Annual Wellness Visit Health Risk Assessment

The annual wellness visit (AWV) includes a health risk assessment (HRA). View the HRA minimum elements summary below. A Framework for Patient-Centered Health Risk Assessments has more information, including a sample HRA.

Perform an HRA

• You or the patient can update the HRA before or during the AWV
• Consider the best way to communicate with underserved populations, people who speak different languages, people with varying health literacy, and people with disabilities
• Demographic data
• Health status self-assessment
• Psychosocial risks, including, but not limited to, depression, life satisfaction, stress, anger, loneliness or social isolation, pain, suicidality, and fatigue
• Behavioral risks, including, but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (for example, seat belt use), and home safety
• Activities of daily living (ADLs), including dressing, feeding, toileting, and grooming; physical ambulation, including balance or fall risks and bathing; and instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, transportation, shopping, managing medications, and handling finances

1. Establish the patient’s medical and family history

At a minimum, document:

• Medical events of the patient’s parents, siblings, and children, including hereditary conditions that place them at increased risk
• Use of, or exposure to, medications, supplements, and other substances the person may be using

2. Establish a current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure
• Other routine measurements deemed appropriate based on medical and family history

4. Detect any cognitive impairments the patient may have

Check for cognitive impairment as part of the first AWV.

Assess cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others. Consider using brief cognitive tests, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Alzheimer’s and Related Dementia Resources for Professionals has more information.

5. Review the patient’s potential depression risk factors

6. Review the patient’s functional ability and level of safety

• Ability to perform ADLs

7. Establish an appropriate patient written screening schedule

Base the written screening schedule on the:

• Checklist for the next 5–10 years
• United States Preventive Services Task Force and Advisory Committee on Immunization Practices (ACIP) recommendations
• Patient’s HRA, health status and screening history, and age-appropriate preventive services we cover

8. Establish the patient’s list of risk factors and conditions

• A recommendation for primary, secondary, or tertiary interventions or report whether they’re underway
• Mental health conditions, including depression, substance use disorders , suicidality, and cognitive impairments
• IPPE risk factors or identified conditions
• Treatment options and associated risks and benefits

9. Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs

Include referrals to educational and counseling services or programs aimed at:

• Fall prevention
• Physical activity
• Tobacco-use cessation
• Social engagement
• Weight loss

10. Provide advance care planning (ACP) services at the patient’s discretion

ACP is a discussion between you and the patient about:

• Preparing an advance directive in case an injury or illness prevents them from making their own health care decisions
• Future care decisions they might need or want to make
• How they can let others know about their care preferences
• Caregiver identification
• Advance directive elements, which may involve completing standard forms

Advance directive is a general term that refers to various documents, like a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. The Advance Care Planning fact sheet has more information.

We don’t limit how many times the patient can revisit the ACP during the year, but cost sharing applies outside the AWV.

11. Review current opioid prescriptions

• Review any potential OUD risk factors
• Provide information about non-opioid treatment options

12. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them for treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

13. Social Determinants of Health (SDOH) Risk Assessment

Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and ensure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate.

1. Review and update the HRA

2. Update the patient’s medical and family history

At a minimum, document updates to:

3. Update current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including those added because of the first AWV personalized prevention plan services (PPPS), and any behavioral health providers.

• Weight (or waist circumference, if appropriate) and blood pressure

5. Detect any cognitive impairments patients may have

Check for cognitive impairment as part of the subsequent AWV.

6. Update the patient’s written screening schedule

Base written screening schedule on the:

7. Update the patient’s list of risk factors and conditions

• Mental health conditions, including depression, substance use disorders , and cognitive impairments
• Risk factors or identified conditions

8. As necessary, provide and update patient PPPS, including personalized health advice and appropriate referrals to health education or preventive counseling services or programs

9. Provide advance care planning (ACP) services at the patient’s discretion

10. Review current opioid prescriptions

11. Screen for potential substance use disorders (SUDs)

12. Social Determinants of Health (SDOH) Risk Assessment

Preparing Eligible Patients for their AWV

Help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment:

• Medical records, including immunization records
• Detailed family health history
• Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
• Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists

Use these HCPCS codes to file AWV claims:

Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

Report a diagnosis code when submitting AWV claims. We don’t require you to use a specific AWV diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an AWV if performed by a:

• Medical professional (including health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of medical professionals directly supervised by a physician

When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV, and G0439 is for subsequent AWVs. Don’t bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. We deny these claims with messages indicating the patient reached the benefit maximum for the time period.

Medicare telehealth includes HCPCS codes G0438 and G0439.

ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a patient to discuss their health care wishes and medical treatment preferences if they become unable to communicate or make decisions about their care. At the patient’s discretion, you can provide the ACP during the AWV.

Use these CPT codes to file ACP claims as an optional AWV element:

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Report a diagnosis code when submitting an ACP claim as an optional AWV element. We don’t require you to use a specific ACP diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

We waive both the Part B ACP coinsurance and deductible when it’s:

• Provided on the same day as the covered AWV
• Provided by the same provider as the covered AWV
• Billed with modifier 33 (Preventive Service)
• Billed on the same claim as the AWV

We waive the ACP deductible and coinsurance once per year when billed with the AWV. If we deny the AWV billed with ACP for exceeding the once-per-year limit, we’ll apply the ACP deductible and coinsurance .

We apply the deductible and coinsurance when you deliver the ACP outside the covered AWV. There are no limits on the number of times you can report ACP for a certain patient in a certain period. When billing this service multiple times, document changes in the patient’s health status or wishes about their end-of-life care.

SDOH is important in assessing patient histories; in assessing patient risk; and in guiding medical decision making, prevention, diagnosis, care, and treatment. In the CY 2024 Medicare Physician Fee Schedule final rule , we added a new SDOH Risk Assessment as an optional, additional element of the AWV. At both yours and the patient’s discretion, you may conduct the SDOH Risk Assessment during the AWV.

Use this HCPCS code to file SDOH Risk Assessment claims as an optional AWV element:

Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes

Report a diagnosis code when submitting an SDOH Risk Assessment claim as an optional AWV element. We don’t require you to use a specific SDOH Risk Assessment diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

The implementation date for SDOH Risk Assessment claims is July 1, 2024. We waive both the Part B SDOH Risk Assessment coinsurance and deductible when it’s:

We waive the SDOH Risk Assessment deductible and coinsurance once per year when billed with the AWV.

If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when you deliver the SDOH Risk Assessment outside the covered AWV.

AWV Resources

• 42 CFR 410.15
• Section 140 of the Medicare Claims Processing Manual, Chapter 18

No. The AWV isn’t a routine physical some patients may get periodically from their physician or other qualified NPP. We don’t cover routine physical exams.

No. We waive the coinsurance, copayment, and Part B deductible for the AWV.

We cover an AWV for all patients who’ve had Medicare coverage for longer than 12 months after their first Part B eligibility date and who didn’t have an IPPE or AWV within those past 12 months. We cover only 1 IPPE per patient per lifetime and 1 additional AWV every 12 months after the date of the patient’s last AWV (or IPPE). Check eligibility to find when a patient is eligible for their next preventive service.

Generally, you may provide other medically necessary services on the same date as an AWV. The deductible and coinsurance or copayment applies for these other medically necessary and reasonable services.

You have different options for accessing AWV eligibility information depending on where you practice. Check eligibility to find when a patient is eligible for their next preventive service. Find your MAC’s website if you have specific patient eligibility questions.

Know the Differences

An IPPE is a review of a patient’s medical and social health history and includes education about other preventive services .

• We cover 1 IPPE per lifetime for patients within the first 12 months after their Part B benefits eligibility date
• We pay IPPE costs if the provider accepts assignment

An AWV is a review of a patient’s personalized prevention plan of services and includes a health risk assessment.

• We cover an annual AWV for patients who aren’t within the first 12 months after their Part B benefits eligibility date
• We cover an annual AWV 12 months after the last AWV’s (or IPPE’s) date of service
• We pay AWV costs if the provider accepts assignment

A routine physical is an exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.

• We don’t cover routine physical exams, but the IPPE, AWV, or other Medicare benefits cover some routine physical elements
• Patients pay 100% out of pocket

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CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Please wait while your request is being processed., this link will leave wellcare.com, opening in a new window., annual wellness visit and additional annual physical coding refresher.

Because WellCare members are encouraged to receive an annual wellness visit and a physical exam each calendar year, we’d like to share a brief overview of the codes and applicable time intervals for these services.  

Wellness Visits

G0402 -  The Initial Preventative Physical Examination with EKG (IPPE) is offered once in a lifetime and must occur  within  the first 12 months of Medicare eligibility. This is the “Welcome to Medicare” visit that consists primarily of discussion and personalized prevention planning.

G0438 -  The Initial Annual Wellness Visit with Health Risk Assessment (Initial AWV w/ HRA) is offered once in a lifetime and must occur  after  the first 12 months of Medicare eligibility and if the member did not receive an IPPE (G0402). This is very similar to the “Welcome to Medicare” visit as it consists primarily of discussion and personalized prevention planning.

G0439 -  The Subsequent Annual Wellness Visit with Health Risk Assessment (Subsequent AWV w/ HRA) is offered once per year and must occur  after  the first 12 months of eligibility and 11 months after receiving and IPPE (G0402) or Initial AWV (G0438).

Physical Exam

993XX –  The preventative visit with physical exam is offered once per year as an added benefit through WellCare. ( Preventative visit code selection is age driven ).

We hope that this is helpful, and we appreciate the care our providers give to our members!

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Annual Wellness Visit | Advance Care Planning | Social Determinants of Health | CPT codes

Annual Wellness Visits: 2024 CPT Codes and Reimbursement Rates

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February 12th, 2024 | 1 min. read

ThoroughCare

Content Team

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Annual Wellness Visits (AWV) can be an effective way to embrace value-based care, so it’s important to understand the program's rules and regulations, as well as the different types of AWVs your practice can offer.

In this video, we'll review the 2024 CPT codes and reimbursement rates for AWVs, Advance Care Planning (ACP), and the new Social Determinants of Health (SDoH) assessment including G0402, G0438, G0439, G0468, 99497, 99498, and G0136.  We’ll cover the differences between Initial Preventive Physical Examinations (IPPE), Initial Annual Wellness Visits, Subsequent Annual Wellness Visits and when each can be administered. 

After watching, you’ll have a better understanding of the elements of an AWV, including health risk assessments, ACP, and the SDoH assessment. You'll also know how to bill for each type of visit if you’re a physician practice, Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC).

Download an Annual Wellness Visit CPT code brochure .