A 68-year-old patient comes in for her "annual physical". She has been on Medicare for three years and has never had a wellness visit. The provider does a thorough exam, orders labs, adjusts her blood pressure medication and bills 99397 with a Z00.00 diagnosis. Medicare denies it, because Medicare does not cover routine physicals. The practice writes it off, or worse, bills the patient, who is angry because she was told Medicare covers an annual visit. It does. Just not that one.
The annual wellness visit is the most misunderstood service in primary care billing. It is not a physical. It is a structured preventive planning visit with specific required elements, its own HCPCS codes, and a frequency rule that trips practices every year. Done right, it pays reasonably, has no deductible or coinsurance for the patient, and produces the documentation that closes care gaps. Done wrong, it produces denials and patient complaints. This is how we teach it.
Key takeaways
- Three codes in sequence: G0402 in the first 12 months of Part B, G0438 once for the first wellness visit after that, G0439 every year after.
- "Annual" means the patient is eligible again in the twelfth month after the last visit's month; check the preventive eligibility dates on the 271 before scheduling.
- The note is defined by its elements, not by an exam; a structured template with the health risk assessment done before the visit is the only reliable way to hit every one.
- A same-day problem visit is billable with modifier 25 if the E/M note stands on its own, and the patient owes cost sharing on that line only.
- Commercial payers do not recognize G0438 and G0439; use the 99395 to 99397 family for them, and check each Medicare Advantage plan's preventive schedule.
Three codes, one sequence
| Code | Name | When it applies | Key rule |
|---|---|---|---|
| G0402 | Initial Preventive Physical Examination (IPPE, the "Welcome to Medicare" visit) | Within the first 12 months of Part B enrollment | Once per lifetime; includes an exam component the AWV does not |
| G0438 | Annual wellness visit, initial | First AWV, more than 12 months after Part B enrollment and not within 12 months of an IPPE | Once per lifetime |
| G0439 | Annual wellness visit, subsequent | Every year after the initial AWV | At least 11 full months must pass since the last AWV |
The frequency rule is where the denials come from. "Annual" for Medicare means the patient is eligible again in the twelfth month after the previous visit's month, not 365 days later. A G0439 on June 15, 2023 makes the patient eligible again on June 1, 2024. Bill it on May 28 and it denies. Bill G0438 for a patient who had one at a previous practice and it denies. The eligibility response (the 271) from Medicare includes the next eligible dates for preventive services; use it before scheduling, not after the denial.
What has to be in the note
The AWV is defined by its elements, and an auditor will look for each one. For the initial AWV: a health risk assessment completed by or with the patient; medical and family history; a list of current providers and suppliers; measurements (height, weight, BMI, blood pressure); detection of cognitive impairment; a review of risk factors for depression and of functional ability and safety; a written screening schedule for the next five to ten years; a list of risk factors and conditions with interventions recommended; personalized health advice and referrals; and, at the patient's discretion, advance care planning. Since January 2024 a social determinants of health risk assessment is an optional element as well, billable separately as G0136 with cost sharing waived when it is performed with the AWV. The subsequent AWV updates each of these rather than repeating them from scratch. There is no required physical exam beyond the measurements, which surprises providers who were trained to do one.
The practical answer is a structured template that walks through every element, with the health risk assessment done by the patient in the waiting room or the portal before the visit. Practices that try to do the AWV as a free-text note miss elements, and practices that let a medical assistant complete the whole thing without the provider reviewing it have a different problem. In audits we see subsequent AWV notes that are the previous year's note copied forward with a new date, and those fail on the first element an auditor checks: the updated list of providers and suppliers.
Adding a problem visit the same day
Patients do not come in with only prevention on their minds. When the provider also addresses an acute or chronic problem that requires separate medical decision making, an E/M service can be billed on the same day with modifier 25. A common combination is G0439 plus 99214-25 with the problem diagnoses on the E/M line and Z00.00 or Z00.01 on the AWV line. The patient owes cost sharing on the E/M, not on the AWV, and that is the conversation to have at check-out before the statement surprises them.
The documentation must support both. The E/M note has to stand on its own: the problem, the assessment, the plan, the medical decision making. A provider who writes "also refilled lisinopril" has not documented a 99214. In audits we see modifier 25 claims where the AWV template and the problem note are the same paragraph, and those do not hold up. One more 2024 wrinkle: Medicare does not currently pay the G2211 visit complexity add-on when the E/M carries modifier 25, so an AWV plus a problem visit loses the add-on. The proposed 2025 fee schedule released on July 10 would change that for E/M visits performed with an annual wellness visit, which is worth watching in the final rule this fall.
Other services that pair with the AWV
- Advance care planning (99497, and 99498 for each additional 30 minutes). When performed on the same day as the AWV and billed with modifier 33, the patient's deductible and coinsurance are waived. Without the AWV, cost sharing applies.
- Annual depression screening (G0444). Billable with a subsequent AWV (G0439) but not with the initial one, where depression risk review is already included.
- Alcohol misuse screening (G0442) and counseling (G0443), and cardiovascular risk reduction counseling (G0446), each with its own frequency limit.
- Social determinants of health risk assessment (G0136), once a year, with cost sharing waived when performed with the AWV.
- Immunizations given at the visit, billed with their administration codes.
The denials, and what causes them
| Denial | Cause | Prevention |
|---|---|---|
| Frequency, often CO-119 (benefit maximum reached) | AWV billed before the eligible month, or G0438 billed for a patient who already had one | Check preventive eligibility dates on the 271 before scheduling |
| Not covered, often CO-96 with a remark code | 99395 to 99397 billed to Medicare for a routine physical | Medicare does not cover routine physicals; schedule and code an AWV |
| IPPE denied | G0402 billed more than 12 months after Part B began | Confirm the Part B effective date; bill G0438 instead if past 12 months |
| E/M bundled or denied with the AWV | Modifier 25 missing, or the E/M note does not support a separate service | Modifier 25 on the E/M; separate documentation |
| G0444 denied with G0438 | Depression screening billed with the initial AWV | Bill G0444 only with G0439 |
Medicare Advantage and commercial plans
Medicare Advantage plans cover the AWV with the same codes and generally the same frequency rule, but some plans also pay for a separate annual physical, and some have their own supplemental codes. Check each plan's preventive schedule. Commercial payers do not recognize G0438 and G0439 at all; for those patients, the preventive medicine codes 99395 to 99397 are correct. Setting the wrong code family by payer is the second most common AWV error after frequency, and the fix is a payer-specific rule in the scrubber that flags a G0439 on a commercial claim before it leaves.
A worked example
A fictional 72-year-old patient, on Medicare since 2017, had a G0439 in March 2023. She is scheduled in July 2024 for her wellness visit. The 271 confirms she is eligible for G0439. She completes the health risk assessment in the portal. At the visit the provider updates the history, providers list, measurements and screening schedule, screens for depression (G0444), completes 20 minutes of advance care planning at her request (99497-33), and separately evaluates a two-week cough with a chest exam and a decision to treat (99213-25, J20.9). The claim carries G0439 with Z00.00, G0444, 99497-33, and 99213-25 with J20.9. The patient owes cost sharing only on the 99213, and the check-out staff tell her so before she leaves.
Questions we hear
Can a nurse practitioner or a medical assistant do the AWV?
Physicians, nurse practitioners, physician assistants and clinical nurse specialists may furnish it. Other medical professionals, including a registered nurse or health educator, may furnish it under the direct supervision of a physician, per Medicare's rules. The billing provider is responsible for the content either way.
Why do patients think the AWV is a physical?
Because everyone calls it one. Train the front desk to say "Medicare wellness visit" and to explain in one sentence that it is a planning visit, not a head-to-toe exam, and that any problems addressed may have a copay. That sentence prevents most of the complaints.
Is the AWV worth the effort for the practice?
For most primary care practices, yes. The visit itself pays, the cost-sharing waiver removes the collection problem, and the health risk assessment and screening schedule surface the care gaps that quality programs measure. Our closing gaps in care work often starts with AWV outreach for exactly this reason, and our medical billing team checks preventive eligibility as part of the pre-visit process.
What to do this week
- Run a report of Medicare patients with no AWV in the last 12 months and sort it by the month they become eligible.
- Add the preventive eligibility dates from the 271 to the scheduling script so nobody books a G0439 before the eligible month.
- Review your AWV template against the element list above and fix any element that is missing or free-text.
- Move the health risk assessment to the portal or the waiting room so it is done before the provider walks in.
- Add a scrubber rule that flags G0438 or G0439 on a commercial claim and 99395 to 99397 on a Medicare claim.
- Give check-out staff the one-sentence explanation of why a same-day problem visit carries a copay and the wellness visit does not.
