annual wellness visit medicare reimbursement

Yearly "Wellness" visits

If you’ve had Medicare Part B (Medical Insurance) for longer than 12 months, you can get a yearly “Wellness” visit to develop or update your personalized plan to help prevent disease or disability, based on your current health and risk factors. The yearly “Wellness” visit isn’t a physical exam.

Your first yearly “Wellness” visit can’t take place within 12 months of your Part B enrollment or your “Welcome to Medicare” preventive visit. However, you don’t need to have had a “Welcome to Medicare” preventive visit to qualify for a yearly “Wellness” visit.

Your costs in Original Medicare

You pay nothing for this visit if your doctor or other health care provider accepts assignment .

The Part B deductible  doesn’t apply. 

However, you may have to pay coinsurance , and the Part B deductible may apply if your doctor or other health care provider performs additional tests or services during the same visit that Medicare doesn't cover under this preventive benefit.

If Medicare doesn't cover the additional tests or services (like a routine physical exam), you may have to pay the full amount.

Your doctor or other health care provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your doctor develop a personalized prevention plan to help you stay healthy and get the most out of your visit. Your visit may include:

• Routine measurements (like height, weight, and blood pressure).
• A review of your medical and family history.
• A review of your current prescriptions.
• Personalized health advice.
• Advance care planning .

Your doctor or other health care provider will also perform a cognitive assessment to look for signs of dementia, including Alzheimer’s disease. Signs of cognitive impairment include trouble remembering, learning new things, concentrating, managing finances, and making decisions about your everyday life. If your doctor or other health care provider thinks you may have cognitive impairment, Medicare covers a separate visit to do a more thorough review of your cognitive function and check for conditions like dementia, depression, anxiety, or delirium and design a care plan.

If you have a current prescription for opioids, your doctor or other health care provider will review your potential risk factors for opioid use disorder, evaluate your severity of pain and current treatment plan, provide information on non-opioid treatment options, and may refer you to a specialist, if appropriate. Your doctor or other health care provider will also review your potential risk factors for substance use disorder, like alcohol and tobacco use , and refer you for treatment, if needed. 

Related resources

• Preventive visits
• Social determinants of health risk assessment

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Common questions about Medicare annual wellness visits

If you are a Medicare recipient, you can take advantage of annual wellness visits. These visits are a preventive health benefit available after having Medicare Part B coverage for at least one year. All Medicare Advantage Plans are required to offer annual wellness visits for their members. A nurse or nurse practitioner reviews your health status and helps you plan for health and wellness needs.

In most cases, the annual wellness visit will be followed by a separate medical visit  with your primary care professional to close any health care gaps and address any problems identified during the visit.

Here are answers to common questions about annual wellness visits.

Why are annual wellness visits important.

The annual wellness visit allows you to review your health history and identify any current or potential health risks with a health care professional. The visit enables the nurse to focus on prevention and wellness while making sure you are current on recommended immunizations and health screenings like colonoscopies or mammograms. It also allows your primary care professional more time to focus on your medical concerns and needs at a separate physical exam.

Do I need to be 65 or older to have an annual wellness visit?

You do not need to be 65 or older to qualify for an annual wellness visit as long as you've been on Medicare Part B for at least one year.

How is an annual wellness visit scheduled?

If you are due for an annual wellness visit, you may be prompted to self-schedule the visit in the patient portal . You also may call your care team and ask to be scheduled.

If your visit is with a nurse or nurse practitioner, it's recommended to schedule this visit before the visit with your primary care professional. This allows your primary care professional the chance to address any concerns mentioned during your annual wellness visit.

How can I prepare for my annual wellness visit?

You may be asked to complete some questionnaires before arriving for your appointment, which will be sent to your patient portal account. If you cannot access the questionnaires before the appointment, plan to arrive at your appointment early to complete them.

It's helpful to come prepared to your visit with this information:

• All medications, vitamins and supplements you take, including how much and how often you take them
• Additional medical records, including immunization records
• Dates of your most recent preventive services, like a colonoscopy or mammogram, if completed by another health care facility
• Family health history, with as much detail as possible
• List of medical providers and suppliers who provide you care, equipment or services

What can you expect during an annual wellness visit?

During the visit, you'll meet with a nurse or nurse practitioner to:.

• Evaluate your fall risk
• Measure your height, weight and blood pressure
• Offer referrals to other health education or preventive services
• Provide information related to voluntary advance care planning
• Screen for cognitive impairments like dementia
• Screen for depression
• Update your medical and family history

What is the cost of an annual wellness visit?

Medicare offers the visit at no cost for people who have Medicare Part B coverage for at least one year before the visit. If you are referred for other tests or services, they will be billed to your insurance. If you have a separate visit with your primary care professional following your annual wellness visit, you or your insurance carrier will be responsible for the cost of that visit.

Robert Stroebel, M.D. , is a Community Internal Medicine, Geriatric and Palliative Care physician at Mayo Clinic Primary Care in Rochester and Kasson, Minnesota.

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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.

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• Care Coordination
• Preventitive and Wellness Programs
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Annual Wellness Visit | CPT codes

2023 Annual Wellness Visit CPT Codes: G0402, G0438, G0439

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January 25th, 2023 | 8 min. read

ThoroughCare

Content Team

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Understanding the billing codes for Medicare Annual Wellness Visits (AWVs) can provide a better idea of what is expected, both by the patient and by the payer. Understanding billing codes may also help you project revenues and optimize your staff’s capacity .

At ThoroughCare , we’ve worked with clinics and physician practices nationwide to help them streamline and capture Medicare reimbursements. Our software solution assists with the rules and regulations for AWVs while also tracking all activities related to providing the program and easing the difficulties of billing.

What are Annual Wellness Visits?

Annual Wellness Visits are free for anyone covered by Medicare Part B and include a yearly assessment of a patient’s health and overall well-being. They are designed not as a yearly physical examination, but as a critical care marker that bridges gaps in the yearly physical exam while developing and updating a patient’s personalized plan of care.

That personalized care plan is designed to help prevent disease and disability and is based on the patient’s current health and determined risk factors. The overall goal is to establish a record of the patient’s physical and mental well-being for the purpose of preventive health planning .

AWVs Include:

• A health risk assessment (HRA)
• A review and update of medical and family history
• A review of current providers, prescriptions/medications, and durable medical equipment suppliers
• Height, weight, blood pressure, BMI, and other routine measurements
• Personalized health advice, health education, and preventative counseling
• A list of identified risk factors, current medical and mental health conditions, and recommended treatment options
• A cognitive impairment screening
• A five to 10-year screening schedule for appropriate preventive services
• A review of the patient’s functional ability and level of safety, including screening for hearing impairments, risk of falling, activities of daily living, and level of home safety
• Identification of patients at risk for alcohol, tobacco, and opioid abuse
• Advance care planning

There are three types of wellness visits : Initial Preventive Physical Examination (IPPE), an Initial Annual Wellness Visit, and the Subsequent Annual Wellness Visit. Each entails a different billing code as well as specific qualifiers for each program.

• Initial Preventive Physical Examination: Patients may only receive this benefit within the first 12 months of their Medicare enrollment . Commonly referred to as the “welcome to Medicare visit,” it is considered a once in a lifetime assessment and after the initial eligibility period, the patient cannot receive an IPPE. It is also dependent on the HRA .
• Initial Annual Wellness Visits : Similar to an IPPE, except it is available to a patient after 11 months of Medicare enrollment . This is for patients that miss their window for an IPPE. However, if the patient does complete an IPPE, they must still complete the Initial Annual Wellness Visit. This screening also includes an optional cognitive exam and end-of-life planning. 
• Subsequent Annual Wellness Visit: Is the yearly follow-up to an Initial Annual Wellness Visit . Eleven full months after the Initial Annual Wellness Visit, a patient can attend these visits to modify and maintain their preventive care plan, based on how their health is at any given time. 

As the patient’s health evolves over time, a doctor may use the Subsequent Annual Wellness Visit to guide them toward other Medicare preventive programs, such as Chronic Care Management (CCM) , Behavioral Health Integration (BHI) , or Remote Patient Monitoring (RPM) . 

Billing Medicare Annual Wellness Visits

Five items are required when submitting a claim through Centers for Medicare & Medicaid Services (CMS) :

• A CPT Code for the specific type of AWV provided
• An ICD-10 code for a general adult medical examination (Z00.00)
• Date of service
• Place of service (most office in-office or telehealth)
• Submit National Provider Identifier (NPI) number

It is helpful to know the care manager assigned to a patient in case of an audit.

Three Steps to Bill for AWVs :

• Verify CMS requirements were met
• Submit claims to CMS annually
• Determine there are no conflicting billing codes

CPT Codes for Annual Wellness Visits

See 2024 reimbursement rates here .

The types of AWVs are reflected in the CPT codes. The crucial qualifying determinant is when a certain AWV can be provided and billed.

AWVs for Federally Qualified Health Centers (FQHC) and Advance Care Planning (ACP)

As shown in the chart above, FQHC are able to bill for AWVs, although they utilize additional codes.

In addition to the standard CPT codes associated with AWVs, FQHC may use a special add-on code (G0468) that will allow them to receive additional reimbursement. For example, if an FQHC were to provide an IPPE, the clinic would bill for G0402 + G0468 for a total average reimbursement of $322. This coding indicates to CMS that the service is being provided through an FQHC. The good news is that these organizations receive much higher average reimbursement rates

Advance care planning (ACP) is not a type of AWV , but it can play a meaningful part in the program. 

ACP is a formal process to understand the patient’s preferences for potential and future medical care, such as end-of-life planning, a living will, and power of attorney. It is an opportunity to craft a patient-centered care plan and an AWV drives just that opportunity. Providers often complete an ACP during an AWV. 

ACP is fully covered for patients under Medicare Part B if it is conducted during the AWV. It is a free service that is an optional element of AWVs. Favorably, it is reimbursable for your practice and can be billed in concurrence with an AWV using CPT code 99497 for the first 30 minutes and 99498 for subsequent 30-minute billing.

Streamline Medicare Annual Wellness Visits

ThoroughCare   offers end-to-end workflow for Annual Wellness Visits.

We simplify the process and help providers engage patients to get their most relevant health information. Guided interviews help ask the right questions and ensure all service requirements are met. ThoroughCare includes digital solutions, such as:

• An interactive health risk assessment
• Screening tools, such as ADL, CAGE, DAST-10, GAD-7, MDQ, PAC, PHQ-2, and a mini cognitive exam
• A care gaps summary with recommended interventions
• A full report of Personalized Prevention Plan Services
• Comprehensive care planning tools
• Automated CPT code assignment for accurate billing

Reimbursement rates are based on a national average and may vary depending on your location.   Check the Physician Fee Schedule   for the latest information.

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The Ultimate Guide to Medicare Annual Wellness Visits

The Medicare  Annual Wellness Visit (AWV)  is a valuable but often underutilized resource. This annual checkup, specifically designed for Medicare beneficiaries, encourages proactive health management, creates customized preventive care plans, and promotes improved quality of life for the recipients. 

Studies  have demonstrated the enormous opportunity for AWVs to facilitate healthy aging among the elderly populace and encourage participants to take advantage of preventive services and mitigate their health risks. AWVs also correlate to a significant reduction in acute hospitalizations and outpatient services, as Medicare patients average  a 5.7% reduction  in healthcare expenditures if they receive an AWV. 

However,  81% of eligible participants  fail to receive the service despite its potential to enhance overall well-being. Patients and providers are often confused about the distinction between AWVs and annual physicals. Furthermore, AWVs can be perceived as disruptive to a practice’s workflow without proper implementation. If practices cannot verify patient eligibility in real-time, they also risk providing a service that does not qualify for reimbursement. 

In this article, we delve into the vital aspects of AWVs, defining the specifics of what an AWV entails, what makes them distinct from other routine annual visits, and how to seamlessly integrate them into your practice through ChartSpan’s RapidAWV™ software. 

What is a Medicare Annual Wellness Visit?

A  Medicare Annual Wellness Visit (AWV)  is a yearly appointment where healthcare providers assess a patient’s health risks, develop personalized prevention plans, recommend screenings, and educate patients on managing their health. AWVs provide customized preventive care, detect potential health risks early on, actively engage patients in their wellness journey, and improve patients’ overall quality of life. 

First introduced in 2011 as part of the Affordable Care Act, Annual Wellness Visits are entirely covered by Medicare and scheduled every 12 months once a patient has been enrolled in Medicare Part B for over a year. 

What happens at an Annual Wellness Visit?

During an Annual Wellness Visit, physicians will review a patient’s medical history and prescription medications and document vital signs like height, weight, body mass index (BMI), and blood pressure. Before the physician’s consultation, patients complete a  Health Risk Assessment (HRA) , a self-guided questionnaire that ascertains details about the patient’s health, medical history, and lifestyle. AWVs also address various factors that influence a patient’s health, like behavioral risks, cognitive ability, depression, nutrition, and  Social Determinants of Health (SDOHs) . 

Annual Wellness Visits are intentionally proactive and designed to promote positive clinical outcomes and quality of life by holistically observing a patient’s health and risk factors. Suppose a patient is living with a chronic illness like diabetes. In that case, the focus of many office visits and yearly examinations may be tied to the patient’s symptoms and concerns about their condition and medications.

The AWV should not also be devoted to discussing the patient's diabetes. The provider will review how the patient's diabetes affects their overall health and long-term clinical prospects, but they will not use the AWV to address treatment for the chronic illness specifically.

Other risk factors may go undetected during sick-care visits, leading to the patient developing additional chronic conditions that further complicate their healthcare journey. Through HRAs and AWVs, physicians can observe a patient’s unique medical history, risk factors, and lifestyle and gain a better understanding of what conditions patients may struggle with in the future. 

Physicians then craft an individualized wellness plan that mitigates health risks and emphasizes preventive action, rather than solely treating the existing symptoms and concerns. 

These preventive health plans promote optimal quality of life for the patient by avoiding injury and disease, minimizing functional decline, and eliminating any outstanding  gaps in care . 

Learn more:  Why Do So Many Providers Fail to Capture AWVs?

What is included in a Medicare Annual Wellness Visit?

A Medicare Annual Wellness Visit may consist of: 

• Providing a patient with a Health Risk Assessment (HRA)
• Measuring a patient’s height, weight, BMI, blood pressure, and other relevant metrics
• Documenting a patient’s personal and family medical history 
• Reviewing a patient’s current medications, healthcare providers, vitamins, and supplements
• Evaluating a patient’s cognitive function and risk for impairments like dementia or Alzheimer’s
• Checking a patient’s functional abilities (dressing, bathing, using the bathroom, etc.) 
• Identifying risk factors, including fall risk assessments, behavioral risks like smoking, sedentary lifestyle, poor nutrition, and other limitations or lifestyle factors that may complicate a patient’s long-term health
• Administering a behavioral health screening for depression
• Discussing Social Determinants of Health (SDOHs) with a patient 
• Providing a patient with personalized health advice for identified risk factors, including resources for exercise, weight management, substance abuse, or smoking cessation
• Discussing  Advance Care Planning  
• Reviewing any opioid medications a patient may be taking 
• Creating a personalized schedule of health screenings and recommended tests based on a patient’s age, medical history, and unique risk factors

Some of the information obtained during an AWV may lead to additional appointments where more robust examinations occur. For example, suppose a physician notices a patient is exhibiting worrisome cognitive issues. In that case, they may schedule a follow-up appointment where they perform more thorough tests for dementia, Alzheimer’s, memory loss, and related behavioral health concerns like anxiety and depression. 

Similarly, a physician may recommend follow-up immunizations, cancer screenings, and lab tests based on information obtained through the HRA and subsequent patient dialogue. These follow-up appointments are a part of the preventive care plan presented to the patient after the AWV. The AWV does not cover these services, and this information should be clearly communicated to patients to minimize confusion.

However, AWVs can be billed concurrently with  problem visits , which is one of the most effective ways to integrate AWVs smoothly into a practice’s pre-existing workflow. When practices can efficiently combine sick visits with the administration of AWVs, they maximize revenue for the visit without sacrificing additional practice resources, demanding additional appointments from the patient, or running the risk of patients skipping the preventive care appointment. (This last point is a particular concern, as studies have shown up to  41%  of preventive care appointments result in patient no-shows.)

Learn more:  The Ultimate Annual Wellness Checklist for Providers

What is not included in an Annual Wellness Visit?

Medicare’s Annual Wellness Visits aim to develop preventive care plans rather than address pre-existing health concerns or be used for routine examinations. Therefore, AWVs do  not  include:  

• Any physical examination of the patient (beyond collecting standard metrics like weight and height) 
• Any blood work, x-rays, or lab tests 
• Treatment of chronic conditions like high blood pressure, diabetes, or arthritis 
• Evaluating, diagnosing, or creating a treatment plan for any new illness or symptom
• Prescription of new medications or adjusting existing medications 
• Performing immunizations

AWVs are not intended to diagnose conditions, treat pre-existing chronic illnesses, or include a hands-on physical examination of the patient. If patients have specific concerns related to their physical health, like new or worsening symptoms, a separate appointment will be necessary to analyze and address these issues thoroughly.

If a provider administers any of these services or other diagnostic care during the appointment, patients should expect a coinsurance or copayment, as these services are explicitly not covered under Medicare’s provisions for preventive AWVs. 

Learn more about what's not covered at a Medicare AWV .

How is the AWV distinct from an Annual Physical?

While an AWV is similar to an annual physical exam and the Initial Preventive Physical Exam (IPPE), also known as the  Welcome to Medicare preventive visit , an AWV is a separate service. AWVs have unique billing codes, Medicare-determined criteria, and a distinct purpose. 

Annual Wellness Visits are focused on creating preventive health plans for patients and do not include physical examination, lab work, or immunization. An Annual Wellness Visit’s primary purpose is for the patient to complete a Health Risk Assessment and for the physician to develop or update a Personalized Prevention Plan (PPP),  according to  the Centers for Medicare & Medicaid Services (CMS) documentation. 

An annual physical exam obtains a clear assessment of the overall state of a patient’s health, observes organ functionality, screens for common types of cancer, and keeps patients up-to-date on recommended vaccinations. Medicare does not cover annual physical exams, but they do cover 100% of AWVs for eligible participants. If a patient is treated for concerns that extend beyond the scope of an AWV, these services will be billed to a patient’s insurance, which may result in unplanned out-of-pocket costs. Patients often need to be made aware of the distinction between AWVs and annual physical exams. If patients do not understand the intention of an AWV, it can lead to confusion, frustration, and dissatisfaction. Physicians must communicate with patients about what to expect during an AWV and the intended outcomes of the appointment. 

Likewise, physicians are often unsure about what an AWV covers and what requires a distinct appointment, which may discourage them from promoting the service to their patients. The low utilization of AWVs, despite  their marked impact  on patients’ engagement with preventive services, indicates that the perceived value of AWVs may be misaligned or that practices cannot effectively integrate them into their office workflow.

Learn more:  The Difference Between Annual Physicals and Annual Wellness Visits

How to educate patients on Annual Wellness Visits

Properly educating patients on the purpose of a Medicare AWV is integral to maintaining patient satisfaction and the overall success of the preventive care plan. A patient who is not interested in preventive care is less likely to follow through on the measures proposed by their physician. A patient expecting to talk with their doctor about their chronic illness or medications may be frustrated by the appointment’s emphasis on medical history, lifestyle, and behavioral risk factors. 

Consider using outreach to inform your patients about the purpose and benefits of receiving AWVs. Your practice can distribute mailed material or electronic communication that tells patients what to expect during an AWV and how receiving AWVs can contribute to increased quality of life. These communications can be timed with holidays or patient birthdays or scheduled annually to ensure the patient gets a yearly reminder. 

Additionally, staff members can educate patients about the differences between physicals and AWVs when they come into the office for a routine visit, differentiating the services and offering to schedule the patient for their initial AWV. Combining AWVs with sick or Evaluation and Management (E/M) visits is also a strategic way to maximize the time spent with the patient and the reimbursements available for providing high-quality and thorough care. 

Who is eligible for an Annual Wellness Visit?

Medicare beneficiaries enrolled in Medicare Part B for over 12 months are eligible for Annual Wellness Visits. Patients cannot receive more than one AWV in a 12-month timeframe. Additionally, patients cannot receive an AWV in the same year as their initial Welcome to Medicare preventive visit (also known as an IPPE). Medicare Advantage plans (Medicare Part C) are also required to cover AWVs when a patient visits an in-network provider and meets the eligibility criteria outlined by Medicare.

Patients looking to schedule an AWV with their healthcare provider should ensure they ask for an “Annual Wellness Visit” by name when setting up the appointment. This will help clarify the intention of the appointment and ensure that Medicare fully covers the service.

Multiple healthcare practitioners, including primary care providers, certain specialty providers, and urgent care providers, can administer AWVs. Medicare will only reimburse practices for one AWV per patient per 12-month cycle, so it is crucial to access accurate patient eligibility data before administering the service. 

Some AWV software,  like ChartSpan’s RapidAWV , syncs with the HETS (HIPAA Eligibility Transaction System) database, allowing front desk personnel to check Medicare beneficiary data in real time. If they discover a patient is indeed eligible for an AWV, they can easily provide the patient with an HRA to complete within the same application. 

Learn more:  How to Identify Eligible Medicare Beneficiaries for Annual Wellness Visits

What is the reimbursement for Medicare Annual Wellness Visits?

Annual Wellness Visits offer between  $118-174 in reimbursements  per visit. The exact amount will differ based on the details of the individual AWV. The Medicare reimbursements may be increased by pairing them with other relevant preventive services, like smoking cessation consultations, advance care planning, or obesity counseling. These additional services have separate CPT billing codes that may be used with the AWV billing codes to maximize practice revenue* further. 

AWVs are an invaluable asset for any practice, as they can add a streamlined revenue channel while encouraging patients to utilize preventive resources and reduce patient healthcare expenses. 

*Results may vary by provider. 

What are the billing codes for Annual Wellness Visits?

There are three primary CPT codes used to bill AWVs to Medicare:

• G0402 (Welcome to Medicare / Initial Preventive Physical Exam):  The IPPE is a one-time, face-to-face service offered to newly enrolled patients in Medicare Part B and is a precursor to subsequent Annual Wellness Visits. This service is only offered in the initial 12-month window after a patient enrolls and will be rejected after that timeframe elapses.
• G0438 (Initial Annual Wellness Visit):  CPT code G0438 is used to bill for a patient’s first Annual Wellness Visit. If patients complete an IPPE, they are eligible for their initial AWV on the first day of the same calendar month a year later. If they do not take advantage of the IPPE, they are eligible for their first AWV twelve months after enrollment in Medicare. The reimbursement for the initial AWV is  higher than subsequent AWVs , so it is critical to correctly bill the service to ensure your practice receives maximum reimbursement for the services rendered. 
• G0439 (Subsequent Annual Wellness Visits):  This billing code is used for every AWV a patient receives after completing their IPPE and initial AWV. They will become eligible for AWVs once every 12 months. This is the only CPT billing code for AWVs that is used more than once.

Apart from the three standard billing codes, multiple codes are relevant to AWVs or often billed in tandem with AWVs. These include: 

• G0468 (FQHC IPPE or AWV) : CPT code G0469 is used by Federally Qualified Health Centers (FQHCs) to bill for visits that include IPPEs or AWVs as part of their bundle of services. Other practices cannot use this code. 
• 99497 (Advance Care Planning):  Advance Care Planning includes discussing and explaining advance directives if a patient becomes debilitatingly ill or otherwise unable to make medical decisions for themselves in the future. When this discussion is provided on the same day as an AWV by the same healthcare provider, it is considered preventive and covered by Medicare. It must be reported with modifier -33 and billed on the same claim as the AWV to waive co-payment. This service can be performed annually. 
• G0444 (Depression Screening):  Depression screenings are often coupled with AWVs and covered by Medicare. They can be performed annually. G0444 cannot be billed with a patient’s initial AWV (CPT code G0438).
• 99406 and 99407 (Counseling to Prevent Tobacco Use):  Medicare covers up to two smoking cessation counseling sessions per patient per year. These are often billed in conjunction with AWVs. 99406 is used for consultations that last between 3 and 10 minutes. Code 99407 is used for consultations that exceed 10 minutes in length. 
• G0442 and G0443 (Alcohol Misuse Screening & Counseling):  G0442 is a screening to detect the risk of alcohol misuse and can be performed once annually. If a patient is identified to be at risk, G0443 is used to bill the subsequent 15-minute behavioral consultation. This service can be performed up to four times per year.
• G0447 (IBT for Obesity):  Patients with a BMI that exceeds 30.0 qualify for obesity consultation services. These can be performed with IPPEs or AWVs and billed up to 22 times in 12 months, depending on the patient’s adherence to the physician’s recommendations and subsequent weight loss. 

Learn more:  CPT Billing Codes for Annual Wellness Visits       

Who can perform a Medicare Annual Wellness Visit?

Any of the following practitioners can  perform  Annual Wellness Visits:

• A physician (doctor of medicine or osteopathy)
• A qualified, non-physician practitioner, including a physician assistant (PA), a nurse practitioner (NP), or a certified clinical nurse specialist (CCNS)
• A medical professional like a registered dietitian, nutrition professional, or health educator, or a team of medical professionals directly supervised by a physician or another licensed healthcare practitioner

It is integral to remember that AWVs can be performed and billed by practices other than primary care facilities. Specialists like cardiologists or neurologists may also submit claims for AWV reimbursement. CMS has intentionally sought to  reduce barriers  to administering AWVs and HRAs to facilitate greater use and easier workflow implementation. 

However, without eligibility verification, this can lead to multiple practices attempting to bill Medicare for the same service and risks patients receiving poorly optimized, duplicated care. Medicare will only reimburse one AWV per patient within a 12-month timeframe. This is why checking patient eligibility in real-time is crucial before practice resources and patient time are devoted to redundant and non-reimbursable services.   

Implement AWVs into your workflow easily with ChartSpan’s RapidAWV™ software

The challenge:  Only  19%  of eligible Medicare patients receive AWVs. When properly implemented into a practice’s workflow, AWVs have the dual benefit of creating an additional revenue stream and facilitating positive patient clinical outcomes by encouraging targeted preventive care. However, many physicians view AWVs as overly time-consuming, staff may struggle to confirm patient eligibility, and many patients do not see the value in an appointment that does not address their current conditions, medications, and physical health. 

Our solution:  ChartSpan’s proprietary RapidAWV™ software  provides healthcare providers with an innovative solution to maximize revenue while significantly minimizing the time and resources required to implement AWVs. 

Real-time eligibility checks

When patients arrive for their scheduled sick visit, clinical staff can use the RapidAWV™ program to check their AWV eligibility via CMS’s HETS database in real time. If the patient is determined eligible for an AWV, your clinical staff can provide an HRA for the patient to complete on a desktop, tablet, or mobile device. These customizable, senior-friendly questionnaires are iOS and Android compatible and  optimized  for access across any device and screen size. 

Accessible and customizable HRAs

The patient can complete their HRA from the comfort of your practice’s waiting room while they await their regularly scheduled appointment, seamlessly integrating the AWV into their pre-existing appointment without causing any disruption to standard  practice workflow . 

These HRAs can be customized by the practice to include questions about medical history, lifestyle, risk factors, and whatever additional information you wish to gather. Upon completion, the software will then deliver a comprehensive, robust report to the attending physician, outlining risk factors and recommended screenings and flagging pertinent factors like nutrition, tobacco use, medication adherence, and vaccinations. 

Personalized preventive care plans

By analyzing the data provided by patients, ChartSpan’s AWV software generates 5- to 10-year preventive care plans with actionable goals, deliberate interventions, and timely follow-ups. It also gives patients clear summaries of their health risks and preventive care plans. 

This automated, data-driven AWV technology dramatically reduces the time required to administer an AWV. This ensures an AWV can be neatly combined with the scheduled appointment yet still deliver a tailor-made preventive care program for the individual patient. 

Partner with ChartSpan to maximize AWVs

With the ease of ChartSpan’s RapidAWV™ software, physicians at your practice can incorporate AWVs into any previously scheduled patient sick visit. Any inconvenience to the patient is minimized by attaching the AWV to a pre-existing appointment, encouraging higher participation. 

Our software checks eligibility instantly, eliminating the risk of your practice providing a non-reimbursable service. Furthermore, the software collects, analyzes, and synthesizes the information provided by the patient into an actionable preventive care plan unique to them, allowing you to maximize every appointment and elevate the quality and scope of care your practice provides. 

To ensure your team’s success with RapidAWV™, ChartSpan provides comprehensive onsite or remote training in our software and a dedicated Client Success Director to help your AWV enterprise flourish. 

Contact us  to learn how ChartSpan can elevate your practice’s care delivery and operational excellence with our industry-leading AWV software.     

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What is an annual wellness visit.

March 28, 2022

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Dear Marci,  

My sister just went to her doctor for an Annual Wellness Visit and recommended I do the same. I don’t think I’ve had this type of appointment before, though. What is it and what should I expect?   

-Douglas (Westminster, CO)  

Dear Douglas,  

The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical. Also, this service is similar to but separate from the one-time Welcome to Medicare preventive visit .  

During your first Annual Wellness Visit, your PCP will develop your personalized prevention plan. Your PCP may also:  

• Check your height, weight, blood pressure, and other routine measurements  
• Give you a health risk assessment  
• Review your functional ability and level of safety  
• Learn about your medical and family history  
• Make a list of your current providers, durable medical equipment (DME) suppliers, and medications  
• Create a written 5-10 year screening schedule or check-list  
• Screen for cognitive impairment, including diseases such as Alzheimer’s and other forms of dementia  
• Screen for depression  
• Provide health advice and referrals to health education and/or preventive counseling services aimed at reducing identified risk factors and promoting wellness  

AWVs after your first visit may be different. At subsequent AWVs, your doctor should:  

• Check your weight and blood pressure  
• Update the health risk assessment you completed  
• Update your medical and family history  
• Update your list of current medical providers and suppliers  
• Update your written screening schedule  
• Screen for cognitive issues  
• Provide health advice and referrals to health education and/or preventive counseling services  

Original Medicare covers the Annual Wellness Visit at 100% of the Medicare-approved amount when you receive the service from a participating provider . This means you pay nothing (no deductible or coinsurance). Medicare Advantage Plans are required to cover AWVs without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s  requirements for the service.  

Contact your healthcare provider if you want to schedule your Annual Wellness Visit!  

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What Does a Medicare Wellness Visit Include?

Routine medical care is important when you’re sick or suffering from an ailment, but what about when you’re feeling fine? The truth is, scheduling an annual doctor’s visit to assess your health, often referred to as a wellness visit, is just as important to do when you’re feeling fine as it is when you’re feeling under the weather. These visits provide your physician the chance to discuss any healthcare concerns you may have, and they also give you the opportunity to ask questions about any medications or supplements you’re taking or about changes to your diet or exercise routine.

The Difference Between a Physical and a Wellness Visit

For many people, the terms “physical” and wellness visit” are used interchangeably, but they are actually quite different. During a physical, your doctor carries out a physical exam of your major systems, takes measurements, documents any changes and reviews concerns. During a wellness visit, there is typically no examination that takes place other than a general inspection of the body. A wellness visit is more like checking in with your doctor while a physical is more like an in-depth examination to assess body systems and functions. During a wellness visit, you may bring up a medical concern which prompts a physical exam, and during a physical, you may discuss wellness concerns, but the two are billed as separate types of visits.

Fortunately for Medicare recipients, an annual wellness visit is included with Part B coverage. During a wellness visit under Medicare, patients will have the chance to discuss any changes to existing conditions that have previously been documented, and the physician will review medical history to ensure that the patient is still in need of any prescribed medications. A doctor may also provide the patient with a preventive health plan designed to encourage healthy lifestyle choices. This plan may detail dietary changes or weight loss exercises, smoking or alcohol cessation information, a list of support groups or therapeutic care providers and more.

While wellness visits usually do not include any type of treatment in the doctor’s office unless an emergency occurs, patients are often directed to make a follow-up appointment for further screening if the wellness visit brings to light concerns that need to be addressed in detail. Keep in mind that this follow-up visit will not be covered as a wellness visit under Medicare and will be billed as a regular outpatient visit.

Additionally, a cognitive assessment is typically performed during the wellness visit, but this is usually done simply by conversing in the office. Finally, patients will fill out a wellness questionnaire while waiting to see the doctor, and the answers will be assessed to ensure that the doctor is able to address any symptoms that are deemed problematic that may not have been expressed directly by the patient.

Medicare Coverage Beyond Wellness Visits

If further medical treatment is required subsequent to a wellness visit, the good news is that Medicare provides a range of coverage options in the forms of inpatient, outpatient and prescription drug benefits. Medicare Part A covers things like inpatient hospitalization and skilled nursing care, and Medicare Part B provides coverage for outpatient care when it comes to doctor’s visits and treatments at clinics or testing at a lab. Medicare Part D is the prescription drug benefit and covers most medications that can be purchased at a retail pharmacy to be administered at home.

If you’re unsure as to your benefits or you’re considering Medicare in the future and would like to know more about your options, contact your current plan and/or research your options to find the Medicare coverage that will meet your needs.

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Billing for a Medicare Annual Wellness Visit: Codes G0438 and G0439

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by Lucy Lamboley

The importance of using preventive medicine to improve the health and ultimately lives of patients is widely recognized. The Medicare annual wellness visit (AWV) plays an important role in helping Medicare beneficiaries stay current with their health and take actions that can prevent illness and reduce risk.

An essential piece of the process required to ensure offering and providing preventive services remains financially viable is for organizations to complete the Medicare annual wellness visit reimbursement coding process accurately. Doing so can help ensure providers receive their earned reimbursements and protect them against possible penalties they might incur from failed coding audits. We know some organizations struggle with meeting compliance requirements set forth by the Centers for Medicare & Medicaid Services. 

In this blog post, we take a look at what's required for compliant AWV coding. While this is by no means a comprehensive guide to Medicare annual wellness visit reimbursement, it provides organizations with information that can assist them in avoiding some of the most common AWV coding mistakes that result in rejected claims, lost revenue, or failed audits — all of which can be mitigated when using Prevounce software. 

Three Unique Annual Wellness Visit Codes: G0402, G0438, and G0439

Medicare preventive wellness visits fall into three categories; the "Welcome to Medicare" visit, also known as the  Initial Preventive Physical Exam  (IPPE); the initial annual wellness visit, and the subsequent annual wellness visits. Each has its own Healthcare Common Procedure Coding System (HCPCS) code that must be used in the right circumstances and proper order. 

Understanding HCPCS G0402

During the first 12 months a patient is enrolled in Medicare, they are eligible for the Welcome to Medicare visit or IPPE. This is a one-time visit that includes vital measurements, a vision screening, a depression screening, and other assessments meant to gauge the health and safety of an individual patient. This visit must be coded using HCPCS G0402. Once a patient has been enrolled for more than 12 months, the G0402 code will be rejected regardless of whether the IPPE visit previously took place or not.

Understanding HCPCS G0438

After a patient has been enrolled in Medicare for 12 months, they become eligible for an annual wellness visit. Note: If you need assistance with identifying eligible patients, get this AWV quick guide .

If the Medicare beneficiary had an IPPE completed, the patient is eligible for the initial AWV on the first day of the same calendar month the following year. An AWV is similar to the IPPE but includes slightly different required and accepted screenings. This initial AWV must be coded using HCPCS G0438. 

Understanding HCPCS G0439

HCPCS G0439 is used to code all subsequent Medicare annual wellness visits that occur after the initial AWV (G0438). So, if used correctly, G0439 would not be used until G0402 was used to code the IPPE and G0438 was used to code the initial AWV. In the case that an IPPE was never completed, G0439 would still be used for any subsequent visits after G0438. 

Purpose of Multiple Annual Wellness Visit HCPCS Codes

Though G0402, G0438, and G0439 are commonly confused, the reason for needing three separate codes is pretty straightforward. It is assumed that the different types of visits take different amounts of resources, and so they are reimbursed at different rates.

For example, the initial annual wellness visit is used to collect the library of information that will be continually updated with each subsequent AWV. As a result, the HCPCS G0438 code is reimbursed at a rate that is nearly 50% higher than HCPCS G0439. So if an organization regularly misses using the G0438 code for an initial Medicare AWV and uses G0439 instead, it could mean numerous denials and a significant loss of revenue. 

Additional AWV HCPCS and CPT Codes

In addition to the primary annual wellness visit codes (G0402, G0438, and G0439), a select list of other codes may be billed for services performed during a Welcome to Medicare visit or AWV. When using any of these codes, a separate note is required to support each rendered service. 

It is important to understand that many of these codes have specific guidelines that require them only to be used with specific visits after meeting certain criteria. For example, HCPCS G0444, which designates a 15-minute annual depression screening, may only be included with subsequent wellness visits billed under G0439. If that specific code is used with the IPPE or initial AWV, it will be rejected as invalid. An abdominal aortic aneurysm (AAA) screening, coded as G0389, may only be performed with the IPPE code G0402. It is not approved for annual wellness visits. 

Advance care planning (CPT 99497) is considered an optional element of the annual wellness visit, which includes a discussion with the patient about their advance care wishes and advance directive. Advance care planning, also referred to as ACP, is considered a preventive service (and thus has its co-pay waived) when billed on the same day as an AWV with modifier -33.

HCPCS G0442 and HCPCS G0443 are additional codes that must be used in conjunction with each other to be valid. G0442 is used for an annual alcohol screening, which should take approximately 15 minutes. G0443 is for 15-minute sessions of alcohol counseling.  According to the Centers for Medicare & Medicaid Services (CMS), the screening service must take place before a counseling service is approved. In other words, if G0443 is used and there are no claims for G0442 in the preceding 12 months, the screening code will be denied. 

Fifteen-minute  obesity counseling  sessions may be billed in conjunction with IPPE visits or annual wellness visits using HCPCS G0447. This service includes dietary assessments and behavioral counseling, but a patient must have a body mass index of thirty or above to qualify.

If you ever have a wellness visit that takes a particularly long time, there is also a set of add-on codes you can use. HCPCS G0513 and HCPCS G0514 are "prolonged preventive service codes" that can be used when a service takes 30 minutes (G0513) or 60-plus minutes (G0514) past the typical duration of the service.

Staying Current With Annual Wellness Visit Coding Requirements 

To avoid risking an audit, it is essential to stay up to date on coding requirements associated with Medicare annual wellness visits as they undergo occasional revisions. For example, in the 2023 Physician Fee Schedule (PFS) final rule , two preventive services had their HCPCS code descriptors modified. HCPCS G0442 was changed to "Annual alcohol misuse screening, 5 to 15 minutes" and HCPCS G0444 was changed to "Annual depression screening, 5 to 15 minutes." The codes currently require a minimum of 15 minutes of services. Such coding revisions and sometimes replacement is relatively common, and utilizing incorrect codes will lead to denied claims.

With changing guidelines and eligibility requirements, the task of coding correctly to better ensure proper reimbursement on preventive health visits can prove challenging for business office staff. But without the necessary revenue, organizations may struggle to support the delivery of preventive health services, which could negatively impact the care given to patients. 

Providing the Annual Wellness Visits and Preventive Care in a Financially Sustainable Way

Medicare annual wellness visits and associated preventive services are not just valuable for patients. Organizations that provide these services can increase their revenue opportunities. In fact, by expanding establishing or growing an AWV program, an organization can generate significant, recurring reimbursement, as is covered in this on-demand webinar .

But Medicare hasn't made it easy for organizations to maintain compliance with its various AWV coding, billing, documentation, and service requirements, as rules undergo regular changes that can easily be missed or misunderstood. Enter Prevounce.

Prevounce lifts the burden of sorting through Medicare regulations to help you understand how preventive services can be utilized to best benefit the patient and your organization. Our platform improves everything from AWV eligibility verification to patient outreach and intake, to billing and coding, to completion of documentation, and more. To learn what Prevounce can do for your AWV program, whether it's in its infancy or ready for significant growth, schedule a demo today ! 

CPT Copyright 2023 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Health economic and reimbursement information provided by Prevounce is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules, and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Prevounce encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services rendered. It is also always the provider’s responsibility to understand and comply with Medicare national coverage determinations (NCD), Medicare local coverage determinations (LCD), and any other coverage requirements established by relevant payers which can be updated frequently. Prevounce recommends that you consult with your payers, reimbursement specialists, and/or legal counsel regarding coding, coverage, and reimbursement matters. Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements. The coding options listed here are commonly used codes and are not intended to be an all- inclusive list. We recommend consulting your relevant manuals for appropriate coding options. The Health Care Provider (HCP) is solely responsible for selecting the site of service and treatment modalities appropriate for the patient based on medically appropriate needs of that patient and the independent medical judgement of the HCP.

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Confusion about the Medicare annual wellness visit

Since its debut last year, the Medicare annual wellness visit (AWV) has been an apparent source of ongoing confusion. That point was driven home to me again this week after I reviewed some Medicare claims data for this service.

As a reminder, there are two codes related to the AWV:  G0438 (includes a personalized prevention plan of service, initial visit) and G0439 ( includes a personalized prevention plan of service, subsequent visit). As the descriptors imply, the initial AWV, should precede a subsequent AWV, and at least 11 months should have elapsed since the month of the initial AWV before a subsequent AWV can be performed and billed.

Both services became Medicare benefits effective Jan. 1, 2011. In 2011, Medicare paid for G0439 (subsequent AWV) more than 50,000 times. Given the timing of the two services and given that a Medicare beneficiary could not receive G0438 (initial AWV) before Jan. 1, 2011, it is not clear how or why any claims for a subsequent AWV (G0439) would have been processed in 2011.

I suspect that G0439 was being reported in 2011 because of confusion regarding its relationship to the Initial Preventive Physical Exam (IPPE, also known as the "Welcome to Medicare Visit"), code G0402. As noted in " When A Medicare Annual Wellness Visit Follows a Welcome to Medicare Physical ," FPM , May/June 2012, "The initial annual wellness visit must take place before a subsequent annual wellness visit in order to establish the required components that will be updated at subsequent visits. The initial annual wellness visit must occur no earlier than the same month of the year following the IPPE." In other words, the inital AWV follows an IPPE and a subsequent AWV follows an initial AWV.

Why the Medicare contractors reimbursed for G0439 in 2011 is a mystery. Apparently, they do not have the capacity or edits in place to recognize when a subsequent AWV is billed erroneously instead of an initial AWV.

For physician practices, this is more than just a matter of miscoding. It is also a matter of lost revenue. Medicare's average allowance for G0438 is $166; for G0439, it is approximately $111. That means that every time you bill G0439 when you should have billed G0438, you are leaving about $55 on the table. Maybe that's why the Medicare carriers were happy to process G0439 claims in 2011.

For more information on the AWV, check out the FPM Topic Collection on Medicare Annual Wellness Visits . 

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• PrEP for HIV: Prepare for Potential Medicare Part B Coverage
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On July 12, 2023,  CMS proposed to transition coverage of Preexposure Prophylaxis (PrEP) using FDA-approved antiretroviral drugs (oral or injectable) to prevent HIV to Medicare Part B. Currently, HIV PrEP drugs may be covered under Medicare Part D.

It’s critical that your patients have uninterrupted access to their HIV PrEP drugs. We encourage you to prepare your systems now so you’re able to immediately transition to Part B coverage if we release a final National Coverage Decision.

Review our  fact sheet (PDF) to learn more about how you can prepare for the possible upcoming coverage change, including information about enrollment, billing, claims processing, and coding. 

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Learn what’s changed :

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Learn  what’s changed (PDF) . CMS  updated payment rules for patients enrolled in Medicare Advantage Organizations.

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