A Medicare Annual Wellness Visit (AWV) is a preventive planning service, not a routine head-to-toe physical. For an independent practice, the billing work begins before the patient arrives: confirm eligibility, identify whether this is the first or a subsequent AWV, and give the clinical team a documentation checklist. CMS reports a 24.5% overpayment rate for AWVs in its 2024 Medicare fee-for-service supplemental improper payment data, making this a worthwhile workflow to audit.
G0438 vs. G0439: choose the right AWV code
Bill HCPCS G0438 for a patient’s first AWV and G0439 for later AWVs. G0438 is a once-in-a-lifetime first AWV code; a later visit does not become another “initial” AWV because the patient is new to your practice. G0402 is the Initial Preventive Physical Exam (IPPE), often called the Welcome to Medicare visit, available during the first 12 months of Part B enrollment. A routine physical exam is a different service and is generally not covered by Medicare as an AWV.
Before scheduling or claim submission, check the patient’s Part B start date and preventive-service history. CMS says not to bill G0438 or G0439 within 12 months of an IPPE or prior AWV, and to bill an AWV no more than once in a 12-month period. Use your eligibility service, Medicare Administrative Contractor portal, or HETS information to verify the next eligible date, including services performed by another practice.
Document the service CMS actually requires
The AWV must include a health risk assessment and a personalized prevention plan. For the first AWV, build a consistent template for medical and family history, current providers and suppliers, height, weight, body mass index or waist circumference, blood pressure, cognitive review, functional ability and safety, a written screening schedule, risk factors, and personalized health advice. Subsequent AWVs update the relevant elements rather than simply copying last year’s note. CMS also describes substance-use screening and an optional physical activity and nutrition risk assessment.
A completed note should show the work performed and the plan given to the patient. Use the diagnosis supported by the visit; CMS does not require one particular diagnosis code for an AWV claim. Missing required elements can create compliance problems even if the claim initially pays.
When an office E/M service happens on the same day
A patient may arrive for an AWV and also need care for a new or worsening condition. CMS may pay for a separately identifiable, medically necessary office or outpatient evaluation and management (E/M) service on the same day. Report the appropriate E/M code with modifier 25 on the E/M line, and document the additional evaluation and management separately from the preventive work. The AWV alone does not justify an extra E/M charge. Tell the patient beforehand that deductible or coinsurance may apply to the problem-oriented service even when the covered AWV has no patient cost sharing.
For qualifying longitudinal care, CMS permits G2211 with an office or outpatient E/M code billed with modifier 25 on the same day as an AWV. This is not an automatic add-on to every wellness visit: confirm that the E/M and G2211 requirements are met and supported in the record.
G0136 and advance care planning: check the 2026 rules
CMS updated G0136 for 2026 to describe administration of a standardized, evidence-based physical activity and nutrition assessment lasting 5–15 minutes, no more often than every six months. When it is provided by the same AWV clinician on the same day and billed on the AWV claim with modifier 33, CMS waives Part B deductible and coinsurance for the covered assessment once per year. When G0136 is provided with an eligible E/M or behavioral health service instead, cost sharing applies. Record the tool, time, findings, and follow-up; do not assume a questionnaire alone supports a separate charge.
Advance care planning is optional and at the patient’s discretion. CMS lists 99497 and, when appropriate, 99498. When the same provider delivers it on the same day as a covered AWV and reports modifier 33 on the AWV claim, CMS waives deductible and coinsurance once per year. Document the discussion and meet the code requirements.
A practical claim checklist for small practices
- Verify Part B enrollment and the last IPPE or AWV date before the appointment.
- Choose G0438 for the first AWV or G0439 for a subsequent AWV; do not substitute a routine physical code.
- Use an AWV template that captures the HRA, required reviews, screening schedule, risk factors, and prevention plan.
- If billing an E/M service, identify the separate medical necessity and put modifier 25 on that E/M line.
- Check G0136 or advance care planning documentation, frequency, same-day conditions, and modifier 33 when applicable.
- Explain any possible patient cost sharing and review denials by reason code each month.
How MABS can help
Independent practices do not need to discover AWV errors one denial at a time. MABS can review eligibility checks, coding, documentation handoffs, modifier use, and unpaid claims as part of a focused revenue cycle review. Our broader coding compliance support helps teams turn payer feedback into a repeatable process. See our guide to revenue leaks in family medicine billing for related checks.
Ready to find preventable claim losses? Request a Free Billing Performance Audit from MABS.
