A primary care office we support scheduled a "Medicare physical" for a 68-year-old in January. The nurse ran through the questionnaire, the physician did an exam, the visit was billed as G0439, and Medicare denied it. The patient had been to a different practice for a wellness visit in March of the prior year, ten months earlier. Nobody checked. The practice ate the visit, and the patient got a confusing letter. This happens in almost every practice we look at, which is why how to bill a Medicare Annual Wellness Visit is a workflow question before it is a coding question.
The Annual Wellness Visit (AWV) is a Medicare Part B benefit that pays the practice to review the patient's health risks, update the list of providers and medications, screen for cognitive impairment and depression, and produce a written prevention plan. It is not a physical exam, which Medicare does not cover. It has no deductible or coinsurance for the patient when billed correctly, it pays reasonably well, and Medicare Advantage plans reward it because it feeds their risk and quality data.
A glossary line for physicians who trained before 2011: the AWV is defined by HCPCS codes G0438 (initial AWV) and G0439 (subsequent AWV), and it is different from the Initial Preventive Physical Examination (IPPE, G0402), which is the one-time "Welcome to Medicare" visit available only in the first twelve months of Part B enrollment. The three codes are a sequence, and the order matters.
Key takeaways
- G0402 is available only in the first twelve months of Part B; G0438 is billed once per lifetime; G0439 is billed every year after that.
- Medicare counts eleven full months since the last AWV before the next one is payable, and the clock follows the patient, not your practice.
- The note must contain a specific list of elements; an ordinary physical exam does not qualify.
- A problem visit on the same day is billable with modifier 25 and does carry patient cost-share.
- Most AWV denials are eligibility and frequency problems, preventable with a check of the patient's preventive service history before the visit.
How to bill a Medicare Annual Wellness Visit: the three codes and the clock
| Code | Description | When it can be billed | Common denial |
|---|---|---|---|
| G0402 | Initial Preventive Physical Examination (IPPE) | Once, within the first 12 months of Part B effective date | Patient past 12 months of Part B; bill G0438 instead |
| G0438 | Initial Annual Wellness Visit | Once per lifetime, more than 12 months after Part B effective date and at least 12 months after any IPPE | Patient already had G0438 elsewhere; bill G0439 |
| G0439 | Subsequent Annual Wellness Visit | Every year, at least 11 full months after the previous AWV | Fewer than 11 full months since the last AWV |
The eleven-month rule trips practices that schedule the AWV on the anniversary date. Medicare requires that eleven full calendar months pass after the month of the last AWV. If the last AWV was March 14, the next one is payable on or after March 1 of the following year, not March 14. Scheduling in the anniversary month is fine; scheduling a few weeks earlier is not.
The clock follows the patient across practices. If the patient had an AWV with another physician, or with a Medicare Advantage plan's in-home assessment vendor, that counts. The only way to know is to check the patient's Medicare eligibility record, which lists the last date each preventive service was paid and the next eligible date. Every MAC portal exposes this, as do most clearinghouse eligibility responses if you request the preventive service benefit segments.
What the note has to contain
The AWV is defined by its content. For the initial AWV (G0438), Medicare expects a health risk assessment completed by or with the patient; a medical and family history; a list of current providers and suppliers; measurement of height, weight, body mass index and blood pressure; detection of any cognitive impairment; a review of risk factors for depression; a review of functional ability and level of safety; a written screening schedule for the next five to ten years; a list of risk factors and conditions with interventions recommended or underway; personalized health advice and referrals; and, at the patient's option, advance care planning.
The subsequent AWV (G0439) updates most of these: the health risk assessment, the history, the provider list, the weight and blood pressure, the cognitive assessment, the screening schedule and the risk factor list, with advice and referrals as appropriate. Since 2024, an optional Social Determinants of Health risk assessment (G0136) can be added when performed with the AWV.
Two things are not required: a hands-on physical exam and a face-to-face physician. The AWV can be furnished by a physician, a nurse practitioner, a physician assistant, or by other health professionals such as a registered nurse or health educator working under the direct supervision of a physician. Many efficient practices run the AWV with a nurse, using a structured template, and pull the physician in only for the problem visit. Medicare also allows the AWV via telehealth.
The template matters more than in almost any other visit type. An auditor reads the note against the element list. If the depression screen isn't there, the visit doesn't qualify, no matter how thorough the rest was. We build AWV templates with every element as a required field, and we ask that the written prevention plan be printed or sent through the portal, because "provided to the patient" is part of the definition.
The same-day problem visit
Patients bring problems to wellness visits. When a problem is evaluated and managed and the work is significant and separately identifiable, bill the appropriate office visit (99212 to 99215) with modifier 25 alongside the AWV. The problem visit carries the normal Part B deductible and 20 percent coinsurance. The AWV does not.
This is where the front desk conversation belongs. Patients understand the AWV as free, because it is. When they receive a bill for a 99213 from the same day, they call. A one-sentence explanation at check-out ("your wellness visit is fully covered; the visit for your knee pain is a separate service with your usual cost-share") prevents most of those calls and most of the requests to "just remove the charge," which you should not do.
Do not roll problem work into the AWV to avoid the conversation, and do not bill a problem visit for the routine review of stable chronic conditions that is part of the AWV's risk factor discussion. The 99214 documentation rules apply in full to the problem portion, and payers do compare AWV-plus-E/M ratios across practices.
The denials and their fixes
Frequency denials arrive as CO-119 (benefit maximum reached) or with a remark that the service was already paid in the period. There is no appeal if the dates confirm it; the fix is the eligibility check before scheduling. If your check shows the patient is not yet eligible, reschedule or offer to convert the visit to a problem visit if there is a problem to address.
Wrong-code denials come from billing G0438 for a patient who had an initial AWV elsewhere, or G0402 for a patient past the first twelve months. The same eligibility record shows which of the three the patient is due for. Submit a corrected claim with the right code.
Medicare Advantage denials often involve the plan's own rules: some plans want the AWV billed with a specific diagnosis code (Z00.00 or Z00.01 is standard), some pay their in-home vendor's assessment first and deny yours as duplicate, and some require the AWV be performed by a contracted primary care provider. Check the plan's preventive services policy, and when the in-home vendor got there first, ask the plan whether it will still pay a practice AWV; several do. Our gaps-in-care work with practices leans on the AWV because it closes several quality measures in one visit, which is also why the plans care about it.
Questions we hear
Can we bill the AWV with a preventive physical code like 99397?
Medicare does not cover 99381 to 99397. Some practices perform a physical, bill 99397 to the patient as non-covered with an Advance Beneficiary Notice, and bill the AWV to Medicare. That is permitted when done transparently and the patient agreed in advance, but it creates confusion and we usually advise against it. Most Medicare Advantage plans, by contrast, do cover an annual physical; check the plan.
Can the AWV be done over telehealth?
Yes. The AWV codes are on the Medicare telehealth list, and the required elements can be gathered remotely, with vitals self-reported or from a recent visit. Follow the current Medicare telehealth billing rules for place of service and modifiers.
What diagnosis code goes on the AWV?
Z00.00 (encounter for general adult medical examination without abnormal findings) or Z00.01 (with abnormal findings) is the usual primary diagnosis. Add the chronic conditions reviewed as secondary diagnoses; they support the risk factor list and, for Medicare Advantage, the plan's risk adjustment.
What to do this week
- Pull every AWV denial from the last six months and sort by reason; most will be frequency or wrong code.
- Add the preventive service eligibility check to the scheduling script for every AWV appointment.
- Audit your AWV template against the required element list and make each element a required field.
- Write the check-out script for the same-day problem visit and train the front desk.
- Run a report of Medicare patients with no AWV in the past twelve months and start outreach; those visits are due and unclaimed.
