medicare annual wellness visit cpt code 2022

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Annual Wellness Visit

What Are the 2022 CPT Codes for Annual Wellness Visits?

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January 12th, 2022 | 6 min. read

ThoroughCare

Content Team

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Medical reimbursements are tied to Current Procedural Terminology (CPT) codes. They categorize and specify billing rates and rules for procedures, treatments, and care services. 

If you’re a medical care provider, you likely know this. But do you know the rates and workflows for Medicare’s wellness programs? Like, Annual Wellness Visits (AWV )? 

Knowing the billing codes for AWVs will give you a better idea of what’s expected, both by the patient and Medicare. 

Understanding billing codes will also help you project revenues and optimize your staff’s capacity . Without this information, you risk disorganization and a clouded outlook. 

At ThoroughCare, we’ve worked with clinics and physician practices across the US  to help them streamline and capture Medicare reimbursements.  Our software solution assists with rules and regulations for AWVs, and it tracks all activities related to providing the program, such as conducting patient assessments, making it easier to bill for. 

In this article, we’ll briefly review the requirements of AWVs, as well as the program’s CPT codes. 

How Do Annual Wellness Visits Work?

As the name suggests, an AWV is a yearly assessment of one’s current health. It is entirely FREE for anyone covered by Medicare Part B. 

A doctor uses the time to discuss health history, identify potential issues and answer an individual’s questions. The overall goal is to establish a record of a person’s physical and mental well-being for the purpose of preventive health planning. 

An AWV should not be confused with a routine physical examination . The AWV is more about recognizing possible gaps in a patient’s healthcare and planning the next steps. It should include:

A review of your medical and family history.

Developing or updating a list of current providers and prescriptions.

Height, weight, blood pressure, and other routine measurements.

Detection of cognitive impairment.

Personalized health advice.

A screening schedule (or checklist) for appropriate preventive services. 

By participating, a patient will receive a personalized risk prevention plan, targeted for specific diseases or disabilities relevant to their situation. 

Wellness visits come in three varieties . 

There is the Initial Preventive Physical Examination (IPPE), an Initial Annual Wellness Visit (IAWV), and the Subsequent Annual Wellness Visit (SAWV). All are fairly similar, yet it’s important to understand the differences as it relates to billing . We’ll cover this more below.

How to Bill for Annual Wellness Visits

There are five items required when submitting a claim through CMS :

• A CPT Code for the specific type of AWV provided
• A ICD-10 code for a general adult medical examination
• Date of service
• Place of service
• Provider name

While it’s not needed, it is helpful to know the care manager assigned to a patient in case you’re ever audited: When billing, you’ll calculate the time spent with each of your patients monthly.

These are the four steps you’ll take when billing:

• Verify CMS requirements were met
• Submit claims to CMS monthly
• Send an invoice to patients receiving an annual visit
• Make sure there are no conflicting codes that have been billed

CPT Codes for Annual Wellness Visits

For 2023 reimbursement information, click here . Below, we break down the four types of billing codes for AWVs, as well as advanced care planning.

For an IPPE, your patients may only receive this benefit within the first 12 months of their Medicare enrollment . It is considered a “once in a lifetime” assessment. After the initial eligibility period, your patient cannot receive an IPPE. It is also dependent on a health risk assessment (HRA) . 

An IAWV is practically identical to an IPPE, except it is available to your patient after 11 months of Medicare enrollment . It is for patients that miss their window for an IPPE. However, if your patient does complete an IPPE, they must still complete the IAWV. An HRA drives the IAWV process, as well. But this screening also includes an optional cognitive exam and “end-of-life” planning. 

The Subsequent AWV is the yearly follow-up to an IAWV . Eleven months after an IAWV, a patient can attend these sessions to modify and maintain their preventive care plan, based on how their health is at any given time. 

As the years pass, and the patient’s health evolves, the doctor may use the Subsequent AWV to guide individuals toward other Medicare preventive programs, such as Chronic Care Management (CCM) , Behavioral Health Integration (BHI) , or Remote Patient Monitoring (RPM) . 

AWV for Federally Qualified Health Clinics and Advanced Care Planning

As shown above, CPT code G0468 allows federally qualified health clinics (FQHC) to bill for AWVs. This code covers all three varieties of AWVs at the same reimbursement rate. 

That said, you would still provide the type of AWV most appropriate based on your patient’s eligibility window. 

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

ACP is a formal process to understand your patient’s preferences for future medical care. It is an opportunity to make a plan. And an AWV can be a chance to create it. Often, providers will complete ACP during an AWV. 

ACP is fully covered for patients under Medicare Part B , so long as it is conducted during the AWV. And it is reimbursable for your practice. It can be billed in concurrence with an AWV using CPT code 99497. 

Streamline AWVs With Care Coordination Software

Knowing  the CPT codes for AWVs  can help your practice project revenue and optimize your care team’s capacity. But t o deliver and document wellness visits, you’ll want a system in place to manage your program.

A practical resource, such as care coordination software , will keep key details from being lost or overlooked. This will promote efficiency for you and your staff and help patients succeed. Care coordination software can streamline the creation of patient care plans, support staff workflows, and simplify billing. ThoroughCare’s software solution offers these exact features. 

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Education, trainings and manuals, regulations, news and insights, annual wellness visit (awv) documentation and coding.

A Medicare Annual Wellness Visit (AWV) is not a typical physical exam. Rather, it’s an opportunity to promote quality, proactive, cost-effective care. AWVs help you engage with your patients and increase revenue.

A physician, PA, NP, certified clinical nurse specialist or a medical professional under the direct supervision of a physician (including health educators, registered dietitians and other licensed practitioners) can perform AWVs.

AWV documentation

Document all diagnoses and conditions to accurately reflect severity of illness and risk of high-cost care.

An ICD-10 Z code is the first diagnosis code to list for wellness exams to ensure that member financial responsibility is $0.

• Z00.00 — encounter for general adult medical examination without abnormal findings
• Z00.01 — encounter for general adult medical examination with abnormal findings

The two CPT® codes used to report AWV services are:*

• G0438 — initial visit**
• G0439 — subsequent visit (no lifetime limits)

Additional services (lab, X-rays, etc.) ordered during an AWV may be applied toward the patient’s

deductible and/or be subject to coinsurance. Before performing additional services, discuss them

with the patient to verify that the patient understands their financial responsibilities.

More information

For additional information and education, contact us at  [email protected] .

*CPT® is a registered trademark of the American Medical Association.

**Code G0438 is for the first AWV only. The submission of G0438 for a beneficiary for which a claim code of G0438 has already been paid will result in a denial.

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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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Prevounce creates wellness that works for everyone, with practice-specific, software-based programs that make preventive care, chronic care management, and remote patient monitoring easier to prep for, perform, document, and bill.

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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.

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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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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