Medicare pays for one annual wellness visit every 12 months and waives the patient’s deductible and coinsurance for it, which makes the visit easy to schedule and easy to misbill. The claim turns on three things: the code the dates support, whether the note carries every required element, and why a problem was managed on the same day. Auditors read the note before they read the claim.
What this covers
- Eligibility is a date, not a finding. G0438 is payable once in a lifetime, and G0439 needs 11 full months to have passed since the IPPE or the prior wellness visit.
- Medicare waives the deductible and coinsurance for the AWV itself and applies both to any medically necessary service furnished the same day.
- The health risk assessment is a defined tool with a 20 minute limit and a fixed topic list, not a narrative paragraph.
- A significant, separately identifiable office visit on the same day takes modifier 25 and its own documentation.
- Medicare put the overpayment rate for AWVs at 24.5 percent in its 2024 data, and a Recovery Audit Contractor topic approved in August 2025 reviews the coding on G0402, G0438 and G0439.
The wellness note is the claim. If a required element is missing from the record, the visit did not happen.Every AWV denial in a contractor review starts with a missing element, not a missing diagnosis.
This is written for the person who owns the template and the charge review: the billing manager, the coder, and the practice owner who signs off on the workflow. The rules below come from 42 CFR 410.15, the Medicare Learning Network products on wellness visits and advance care planning, and the contractor fact sheets that spell out what a reviewer expects.
Three Codes and the Date That Decides Them
The wellness family has three codes and the choice between them is made on dates. G0402 is the Welcome to Medicare exam, paid once per lifetime and only inside the first 12 months of Part B coverage. G0438 is the first annual wellness visit, with the same once per lifetime limit. G0439 covers every annual visit after that. Coverage in 42 CFR 410.15 rests on two conditions: the patient is no longer within 12 months after the effective date of their first Part B coverage period, and no IPPE or AWV has been furnished in the past 12 months.
| Code | What it covers | How often | Timing rule |
|---|---|---|---|
| G0402 | Welcome to Medicare (IPPE) | Once per lifetime | Inside the first 12 months of Part B |
| G0438 | First wellness visit with a personalized prevention plan | Once per lifetime | At least 11 full months after any IPPE |
| G0439 | Subsequent wellness visit | Once every 12 months | At least 11 full months after the prior wellness visit |
| G0468 | Health center visit bundling an IPPE or an AWV | Same limits as the bundled visit | Used in place of the codes above |
The 11 month language is the part practices skip. A visit is not blocked for a full 365 days: once the patient reaches the same calendar month as the prior visit, the next one can be furnished. A patient seen on June 30, 2020 is eligible again on June 1, 2021, and a claim dated May 31, 2021 is too soon. That history lives in Medicare’s claims system, so the check belongs before scheduling, through the HIPAA Eligibility Transaction System or the contractor portal. Date verification of this kind belongs in the same front desk routine that internal medicine revenue cycle management teams run for their preventive codes.
Recovery Audit Contractor topic 0077, approved January 9, 2018, is an automated review of an AWV billed sooner than eleven whole months after the IPPE, and topic 0028 reviews excessive units. Topic 0176, approved August 28, 2025, is a complex review of incorrect coding on G0402, G0438 and G0439 across all A/B MACs, so a records request can arrive before any determination.
The Initial List and the Subsequent List Are Different
The regulation sets minimum elements, and the two visits do not share one list. The first AWV carries height, weight, body mass index and blood pressure. The subsequent visit drops height and BMI and keeps weight or waist circumference with blood pressure. Both require the health risk assessment, an updated medical and family history, the current provider and supplier list, detection of cognitive impairment, the written screening schedule, the risk factor list, personalized advice and referrals where appropriate, and advance care planning at the patient’s discretion.
| Element | First AWV (G0438) | Later AWVs (G0439) |
|---|---|---|
| Health risk assessment | Performed and used | Reviewed and updated |
| Measurements | Height, weight, BMI, blood pressure | Weight or waist circumference, blood pressure |
| Cognitive impairment | Detected and documented | Detected and documented |
| Depression risk factors | Reviewed | Reviewed |
| Functional ability and safety | ADLs, fall risk, hearing, home safety | Same topics |
| Written screening schedule | Established for the next 5 to 10 years | Updated |
| Risk factors and treatment options | Established | Updated |
| Personalized advice and referrals | Furnished | Furnished and updated |
| Advance care planning | Optional | Optional |
| Opioid and SUD screening | Both required | Both required |
Two details carry the denials. The health risk assessment is a defined tool rather than a paragraph: it collects self-reported information, can be completed by the patient or the professional before or during the encounter, takes no more than 20 minutes, and must address demographic data, self-assessment of health status and frailty, psychosocial risks, behavioral risks, and both activities of daily living and instrumental activities of daily living. The visit also has to take the assessment’s results into account, so a completed form that never reaches the prevention plan leaves an element open.
Demographic data. Self-assessment of health status, frailty and physical functioning. Psychosocial risks including depression, stress, loneliness and fatigue. Behavioral risks including tobacco, physical activity, nutrition and home safety. Activities of daily living including dressing, feeding and bathing. Instrumental activities of daily living including shopping, transportation, managing medications and handling finances. Name the instrument and record the result for each domain, because a reviewer who cannot see a result treats the element as absent.
Geriatric panels meet this list first: their patients carry the fall risk, the hearing loss and the depression history the assessment is built to surface. A geriatrics revenue cycle management workflow that treats the note as documentation work gets paid for the visit the specialty next door writes off.
What the Record Has to Show
A contractor reviewer works from a documentation list, and it is shorter than most templates assume. The CGS fact sheet for G0438 and G0439 asks for a progress note that supports medical necessity, carrying the list of providers and suppliers, the cognitive assessment, the depression review, functional ability and safety, the screening schedule, the list of risk factors and conditions, the education and counseling offered, and the signature and credentials of the person who furnished the service.
- Patient identifiers and the date of service on every page of the note.
- The name of each screening instrument and the result it produced.
- The depression review and the cognitive assessment, each with its finding recorded.
- The written screening schedule given to the patient, covering the next 5 to 10 years.
- The risk factor list with treatment options, their risks and their benefits.
- The advice furnished and any referral made, with the program named.
- The signature and credentials of the health professional who furnished the visit.
Elements may be furnished on more than one day. The date of service on the claim is then the day the visit is completed, the record has to show where it started and where it stopped, and both days of documentation can be requested.
When a Problem Is Managed on the Same Day
Assessing and managing an acute or chronic problem is not part of the annual wellness visit, in the regulation or in the template. Medicare still pays for a problem-oriented visit on the same day when it meets the usual test: significant, separately identifiable, and medically necessary to treat the patient’s illness or injury. Report it with the appropriate office visit code and modifier 25, and accept that the deductible and coinsurance apply to that service while the wellness visit stays free to the patient.
- The problem was evaluated, not mentioned. A stable condition recorded for completeness does not carry an office visit level.
- The two services are documented separately. One section for the wellness elements, one for the history, examination and medical decision making behind the problem.
- The level stands on the problem note alone. The wellness content cannot be counted twice toward the office visit.
- Modifier 25 sits on the office visit line. It never goes on the AWV line.
Tell the patient before the visit, because a balance on the explanation of benefits turns into a call to the billing office.
When a contractor reviews a same-day pair, the problem note is read for medical necessity first and the modifier second. A note that repeats the wellness content reads as one visit billed twice, and the recoupment lands on both lines.
Optional Elements Carry Their Own Billing Rules
Three additions sit beside the AWV, and each has a different cost sharing rule. Getting one wrong sends a bill to a patient who was told the visit was free.
- Advance care planning. CPT 99497 covers the first 30 minutes face to face and 99498 each additional 30 minutes. Medicare waives the deductible and coinsurance when the same provider furnishes it on the same day, on the same claim, with modifier 33 on the line. If the AWV falls to the once per year limit, the planning can still be paid as a separate Part B service, with cost sharing switched on.
- The physical activity and nutrition risk assessment. HCPCS G0136 was rewritten for 2026 to describe a standardized, evidence-based assessment of physical activity and nutrition, 5 to 15 minutes, no more often than every 6 months. Billed with modifier 33 on the same claim as the AWV, it costs the patient nothing once a year. Alongside an office visit or a behavioral health service, the deductible and coinsurance apply.
- Depression screening. G0444 covers annual screening of 5 to 15 minutes in a primary care setting with staff-assisted depression care supports in place, with coinsurance and deductible waived. Noridian, the JE contractor, states that it cannot be furnished at the same time as the initial AWV or the IPPE, so read your contractor’s article first.
It is not a routine physical examination, and Medicare excludes that examination by statute. It does not include laboratory tests, though referrals for them are part of the plan. A patient who wants a head to toe physical on the same day needs to hear, before the visit, that the wellness benefit does not cover it.
A Workflow That Survives Review
The overpayment rate on this service is published, which means the weak steps are already known to the people who review the claims.
Pull the prior AWV or IPPE date from the eligibility system or the contractor portal, not from the local chart, and confirm the patient has Part B.
G0402 inside 12 months of Part B, G0438 only when no AWV exists anywhere in the history, G0439 for every later visit.
One for the first visit and one for the subsequent visit, with the instrument name and the result recorded for each domain.
The screening schedule, the risk factor list with treatment options and their risks and benefits, and each referral offered.
A wellness section, a problem section, a level supported by the problem section, and modifier 25 on the office visit line.
Score five completed visits against the element list as a reviewer would, then count the misses by element rather than by clinician.
Pre-bill review is where this pays off. A coder who checks the element list before the charge drops has a note the clinician can still amend; a coder who finds the gap three months later has a claim to refund.
Annual wellness visit billing questions
No. Medicare excludes routine physical examinations by statute, and the wellness visit is not a substitute for one. It is a risk assessment and prevention planning service with a defined element list, and it does not include laboratory tests. If a patient wants a complete physical, explain before the visit that Medicare does not cover that examination.
Yes, when the problem-oriented service is significant, separately identifiable and medically necessary. Report it with modifier 25 and document the problem in its own note. The deductible and coinsurance apply to that visit, while the wellness visit carries no patient cost sharing, so tell the patient at check-in rather than after the explanation of benefits arrives.
Use the patient’s Medicare claims history rather than the local chart. G0438 is payable once per lifetime, so it applies only when no annual wellness visit appears anywhere in the record. Every later visit is G0439. Verify through the HIPAA Eligibility Transaction System or your contractor portal before scheduling, since a prior visit may have been furnished elsewhere.
Medicare denies it with a benefit maximum message, and the visit has to be rebilled after the eligible date. No amount of documentation rescues the claim, because the limit is statutory rather than clinical. An automated Recovery Audit Contractor review covers an AWV billed sooner than eleven whole months after an IPPE.
It is an element at the patient’s discretion, and it can also be billed separately on the same day. CPT 99497 covers the first 30 minutes and 99498 each additional 30 minutes. With the same provider, the same day, the same claim and modifier 33, Medicare waives the deductible and coinsurance. Outside the wellness visit, the patient owes both.
The regulation defines who may furnish it: a physician, a physician assistant, a nurse practitioner, or a clinical nurse specialist, or a medical professional such as a health educator, registered dietitian or nutrition professional, or a team of such professionals working under a physician’s direct supervision. State scope rules still apply, and the record signature must match the professional the claim is billed under.
The bottom line
The annual wellness visit is the easiest preventive service to schedule and the easiest one to lose money on, because what it requires lives in the note rather than the claim. Fix the code selection at scheduling, fix the elements in the template, and keep same-day problems in their own note.
Where does your wellness visit program lose money?
Send us a month of annual wellness visit claims with the notes behind them. We will map each claim to the code the dates support, score the record against the element list, and show you the same-day office visits billed without modifier 25. Our team runs medical billing services for primary care, internal medicine and geriatrics practices.
Request a free wellness visit billing auditFrequency limits, covered elements and contractor instructions change with each Medicare Physician Fee Schedule and each local article, so confirm the current rules with your MAC before rebilling a claim; this is billing guidance, not legal advice.
