Annual Wellness Visit CPT Codes for 2026: G0402, G0438, and G0439

1. Which Annual Wellness Visit Code Applies to Your Patient

The correct annual wellness visit CPT code depends on three things: whether the payer is Medicare or commercial, how long the patient has held Part B, and whether the patient has ever received an annual wellness visit before. Medicare bills the service with HCPCS G-codes G0402, G0438, and G0439.

Quick Answer: The Three Medicare AWV Codes

Code	Visit type	When it applies	Frequency
G0402	Initial Preventive Physical Examination, the Welcome to Medicare visit	Within the first 12 months of Part B enrollment	Once per lifetime
G0438	Initial Annual Wellness Visit	After more than 12 months of Part B, and the patient has never had an AWV	Once per lifetime
G0439	Subsequent Annual Wellness Visit	Every AWV after the initial one	Once per 12-month period

Three Questions That Determine the Code

Three questions settle the annual wellness visit CPT code at the front desk, and a scheduler can answer all three in under a minute with the eligibility file open.

1. Is this patient on Original Medicare, Medicare Advantage, or a commercial plan?
2. What date did this patient’s Part B coverage start?
3. Has this patient had a wellness visit before, here or at any other practice?

Skip those questions and the coder picks from habit. Habit is what produces frequency denials, and Section 20 shows exactly what those denials look like on the remit.

Most coding guides stop at the descriptors. This guide goes past them into the two areas that decide whether the claim pays: the denial codes that fire when eligibility timing slips, and the 2026 payment figures under the new dual conversion factor.

ClaimMax RCM medical billing teams work these claims every week, so the patterns below come out of remittance files rather than code books. Pick the annual wellness visit CPT code from the patient’s coverage history and the claim clears on the first pass.

2. Medicare AWV Billing Rules at a Glance

Fourteen rules govern Medicare AWV billing.

• G0402 is billable once per lifetime, only within the first 12 months of Part B enrollment.
• G0438 is billable once per beneficiary lifetime.
• G0439 is billable once per 12-month period after the initial AWV.
• Do not bill G0438 or G0439 within 12 months of billing G0402 for the same patient.
• The annual wellness visit carries no copayment and no deductible when the provider accepts assignment.
• The annual wellness visit is not a head-to-toe physical examination.
• CMS instructs providers not to bill AWV services using CPT codes 99381 through 99397.
• Z00.00 is the standard primary diagnosis code when screening results are normal.
• A medically necessary, separately identifiable E/M service may be billed the same day with modifier 25 on the E/M code.
• CMS names 99202 through 99205 and 99211 through 99215 as the E/M codes reportable alongside the AWV.
• G2211 is billable with modifier 25 on the same date as G0438 or G0439, effective January 1, 2025.
• G0444 is bundled into G0402 and G0438 and is separately billable only with G0439.
• Medicare pays for G0438 and G0439 when furnished via telehealth.
• FQHCs bill G0468 for a visit that includes an IPPE or AWV.

3. Why “Annual Wellness Visit CPT Code” Is Technically the Wrong Term

The American Medical Association maintains CPT. CMS maintains HCPCS Level II. Medicare bills the annual wellness visit with HCPCS Level II G-codes, not with CPT preventive medicine codes.

CMS Uses HCPCS Level II G-Codes for the AWV

Billing staff call everything on a claim line a CPT code. The habit stays harmless right up to the day somebody submits 99397 to Original Medicare and the remit comes back showing a statutorily excluded service. A vocabulary problem turns into a revenue problem at that moment.

G-codes are not a Medicare-only code set, but the AWV G-codes function that way in practice. A handful of state Medicaid programs and commercial plans recognize Medicare G-codes for office visits; most route preventive care through the CPT family instead, so verify the plan before you assume either direction.

What CMS Says About CPT 99381 Through 99397

CMS states the instruction in one line, and the wording leaves no room for interpretation about which code set applies.

“Do not bill for AWV services using CPT codes 99381-99397.”

Source: CMS Medicare Claims Processing Manual, Chapter 12

That instruction is mandatory. A claim carrying 99397 for an Original Medicare patient will not survive appeal, because the service sits outside the Part B benefit entirely rather than inside it with a documentation gap. Appeals fix documentation problems. Appeals cannot fix a benefit exclusion.

The working rule is short. For Original Medicare, bill HCPCS G0402, HCPCS G0438, or HCPCS G0439. For commercial plans, the 99381 to 99397 preventive medicine family applies, and Section 13 covers that family by age and patient status.

4. The Three Types of Medicare Wellness Visits

Medicare structures preventive visits for Part B beneficiaries as a three-stage sequence. The stage determines the annual wellness visit CPT code on the claim.

1. The Initial Preventive Physical Examination, billed with G0402, is the one-time Welcome to Medicare visit available during the first 12 months of Part B.
2. The Initial Annual Wellness Visit, billed with G0438, is the patient’s first AWV and is available once per lifetime.
3. The Subsequent Annual Wellness Visit, billed with G0439, covers every AWV after the initial one, once per 12-month period.

Three codes exist because the work differs. The initial visit builds the health risk assessment and the personalized prevention plan from nothing. The subsequent visit updates a plan that already exists in the chart. CMS pays them at different rates for that reason, and Section 22 covers the differential.

CMS labels G0438 the PPPS initial visit and G0439 the PPPS subsequent visit in the published descriptors. Sections 5 through 7 carry the eligibility mechanics and a worked scenario for each Medicare wellness visit code.

5. G0402: The Welcome to Medicare Visit (IPPE)

G0402 covers the Initial Preventive Physical Examination, commonly called the Welcome to Medicare visit. G0402 is available only during the first 12 months of Part B enrollment and is a once-per-lifetime benefit.

Coders searching for the Welcome to Medicare CPT code, or for the G0402 CPT code description, land in the same place: HCPCS Level II. Same code, different code set, and the distinction matters only when somebody goes looking in the wrong book.

When to Use G0402

• Part B effective date falls within the preceding 12 months.
• Patient has not previously received the IPPE.
• Service meets the required preventive elements.

When Not to Use G0402

• Patient has held Part B for more than 12 months.
• Patient is presenting for a yearly wellness visit.
• Encounter was problem-focused only.
• Service was a routine physical that does not meet the IPPE requirements.

What G0402 Requires You to Document

• Review of medical and social history, including medications and supplements.
• Depression and mood disorder risk review using a recognized screening tool.
• Functional ability and safety review, including fall risk.
• Measurements: height, weight, BMI, blood pressure, and visual acuity.
• End-of-life planning discussion, a required element with patient consent that the patient may decline.
• Education, counseling, and referral.
• A written screening plan, including ECG referral where appropriate.

Two elements separate G0402 from G0438, and this is where the confusion lives. G0402 includes visual acuity screening and does not require a completed Health Risk Assessment questionnaire. G0438 requires the HRA and carries no visual acuity requirement.

G0402 Example: A Patient Six Months Into Part B

A patient whose Part B coverage started six months ago comes in for a preventive visit. The provider reviews history, screens for depression and fall risk, records the measurements, and builds the written screening plan. G0402 is the correct code.

Screening electrocardiogram carries its own codes, G0403, G0404, and G0405, and its own cost-sharing rules. The ECG referral belongs in the IPPE documentation even when the practice never performs the study.

6. G0438: The Initial Annual Wellness Visit

G0438 covers a patient’s first Annual Wellness Visit. G0438 is billable once per beneficiary lifetime, and only after the patient has held Medicare Part B for more than 12 months.

The G0438 CPT code description in the HCPCS file reads: annual wellness visit, includes a personalized prevention plan of service, initial visit. Two codes cause more mix-ups than the rest of this family, G0438 and the annual wellness visit CPT code that follows it, and the swap runs one direction more than the other.

When to Use G0438

• Patient has held Part B for more than 12 months.
• Patient has never received an AWV under any provider.
• Service includes all required AWV elements.

When Not to Use G0438

• Patient is within the first 12 months of Part B, which calls for G0402.
• Patient has already received an initial AWV, which calls for G0439.
• Fewer than 12 months have passed since a G0402.
• Encounter was problem-focused only.

The 10 Required Components of G0438

1. Health Risk Assessment.
2. Medical and family history.
3. List of current providers and suppliers.
4. Height, weight, BMI, and blood pressure.
5. Cognitive impairment detection.
6. Depression screening.
7. Functional ability and safety assessment, including fall risk and home safety.
8. Written personalized prevention plan with a five to 10 year screening schedule.
9. List of risk factors and conditions with recommended interventions.
10. Written screening and immunization schedule furnished to the patient.

Some practices bill G0438 every year, treating the code as an annual reset. That is the most expensive avoidable error in this code family. Medicare denies the repeat, and a retrospective audit finds each instance going back through the lookback period. Section 21 covers what that audit looks like.

G0438 Example: A Patient Three Years Into Part B With No Prior AWV

A patient enrolled in Part B three years ago has never completed a wellness visit. G0438 is still correct, no matter how much time has passed, because the patient has never had an initial AWV. Long Medicare tenure does not move a patient into G0439.

This scenario is where coders reach for G0439 by mistake. The reasoning sounds right, since a patient on Medicare for years feels like a subsequent-visit patient. Check the AWV history instead of the enrollment length, because G0438 reimburses meaningfully higher than G0439 and Section 22 shows why.

7. G0439: The Subsequent Annual Wellness Visit

G0439 covers every Annual Wellness Visit after the initial one. G0439 is billable once per 12-month period, following a prior G0438 or a prior G0439.

The G0439 CPT code description reads: annual wellness visit, includes a personalized prevention plan of service, subsequent visit. G0439 is the annual wellness visit CPT code most practices bill most often, and coders arrive at it with two questions: the frequency window, and what changed since the initial visit.

When to Use G0439

• Patient has already received an initial AWV.
• The 12-month period since the last AWV has closed.
• Provider updates the risk assessment and the prevention plan.

When Not to Use G0439

• Patient has never received an initial AWV, which calls for G0438.
• The 12-month period has not closed.
• Documentation does not support the required elements.

What Changes Between G0438 and G0439 Documentation

The core elements stay the same between G0438 and G0439, but the emphasis shifts from creating the prevention plan to updating one that already exists. The measurement requirement shifts too, and coding references rarely flag it.

CMS specifies height and BMI as required measurements for the initial AWV under G0438. For the subsequent AWV under G0439, weight and blood pressure are the required measurements, and height and BMI are not explicitly required. Many practices measure all four at every visit, which is fine clinically, though coders should know the documentation requirement differs.

Depression screening carries a second asymmetry, and this one has a dollar figure attached. Screening is bundled into G0438 and is not separately billable with it. With G0439, depression screening under G0444 is separately billable when performed and documented with a standardized tool. Section 18 covers the mechanics.

Practices lose G0444 on every subsequent AWV without noticing, because nothing on a remittance advice announces a code that was never submitted. The only way to catch it is to run the charge capture template against the G0439 encounter list for the quarter.

G0439 Example: The Yearly Follow-Up

A patient completed the initial AWV last year. This year the practice updates the HRA, the medication list, the screening schedule, and the prevention plan. Once the 12-month period has closed, G0439 is correct and the visit codes cleanly.

8. G0402 vs G0438 vs G0439: Side-by-Side Comparison

G0402, G0438, and G0439 differ across six operational variables. The annual wellness visit CPT code that pays is the one matching the patient’s current eligibility window.

G0402	G0438	G0439
Visit type	IPPE	Initial AWV	Subsequent AWV
Eligibility window	First 12 months of Part B	After 12 months of Part B, no prior AWV	12 months after the last AWV
Frequency	Once per lifetime	Once per lifetime	Once per 12-month period
HRA required	No	Yes	Yes, updated
Visual acuity	Yes	No	No
G0444 separately billable	No	No	Yes

One check resolves most of this confusion: pull the Part B effective date and the AWV history before the visit rather than during it. Codes selected from habit instead of from eligibility are the root cause of most frequency denials.

9. Is It 11 Months or 12 Months Between Wellness Visits?

Medicare covers one annual wellness visit per 12-month period. Eligibility returns on the first day of the month in which that 12-month period ends.

Both halves of that rule matter, and the CMS Annual Wellness Visit coverage guidance states the frequency limit without spelling out the calendar mechanics that follow from it.

The Rule, Stated Correctly

A patient receives G0439 on March 15, 2025. The 12-month period closes in March 2026, so eligibility returns on March 1, 2026. Count it out and that lands 11 months and 16 days after the visit. Submit on February 28 and the claim denies. Submit on March 1 and it pays.

Why Sources Disagree

Some sources say 11 months. Others say 12. Both camps are describing the same rule, and neither states it correctly. The 12-month camp misses the first-of-the-month reset and pushes practices past the eligible date. The 11-month camp drops the reset entirely and lands claims before it.

CMS approved a Recovery Audit Contractor topic on this exact point. RAC topic 0077, approved January 9, 2018, targets an AWV billed sooner than 11 whole months following the IPPE. The number in the topic title is 11, which is where a good part of the industry confusion started.

The Scheduling Fix

Front desk staff schedule the next AWV a year out from the last one, which pushes past the eligible date and wastes a month of benefit window. Or they schedule at exactly 11 months, which lands before the first of the month and denies.

Set the scheduling system to calculate the next eligible date as the first day of the month, 12 months out. Then run eligibility verification before every visit against the MAC portal, because the patient may have had an AWV at another practice and nothing in your chart would show it.

Most practices find this rule after the denial rather than before it. If frequency denials keep showing up on your preventive claims, a short eligibility review usually traces the pattern back to the scheduling workflow instead of the coding.

10. How to Select the Correct Annual Wellness Visit Code

Four checks determine the correct annual wellness visit CPT code. Each check produces a code or moves the decision to the next step.

The Four-Step Selection Path

1. Confirm the payer. Original Medicare or Medicare Advantage means G-codes. Commercial means the 99381 to 99397 family. Medicaid varies by state.
2. Check the Part B effective date. Within 12 months means G0402. Beyond 12 months, continue to step three.
3. Check the AWV history. No prior AWV means G0438. Any prior AWV means G0439.
4. Confirm the frequency window has closed. Eligibility returns on the first day of the month, 12 months out.

Image asset: awv-code-selection-decision-tree-2026.png | Alt text: “Decision tree for selecting G0402, G0438, or G0439 based on Medicare Part B enrollment and AWV history.”

Where Code Selection Usually Goes Wrong

• Selecting from habit rather than from the patient’s coverage history.
• Assuming a long-tenured Medicare patient needs G0439 when that patient has never had an initial AWV.
• Treating G0438 as an annual code.

One question decides whether any of this happens: who owns the check? Scheduling knows the appointment date. Billing knows the rule. The check belongs to whoever verifies eligibility before the visit, and in most practices that assignment sits between the two desks. A clean-claim code selection review usually finds the gap in about an afternoon.

11. Annual Wellness Visit vs Annual Physical Exam

The Medicare annual wellness visit is a prevention planning encounter. The annual physical exam is a comprehensive hands-on examination. Original Medicare covers the annual wellness visit and does not cover routine physical examinations.

Annual Wellness Visit	Annual Physical Exam
Purpose	Risk assessment and prevention planning	Comprehensive physical examination
Medicare coverage	Covered when eligibility rules are met	Not covered under Original Medicare
Codes	G0402, G0438, G0439	99381 to 99397
Exam scope	Measurements and screenings only	Full head-to-toe examination
Primary output	Written personalized prevention plan	Examination findings

What Medicare Covers and What It Does Not

CPT preventive medicine codes 99381 through 99387 and 99391 through 99397 are statutorily excluded under Original Medicare. A Medicare patient who wants a true preventive physical pays out of pocket for it, and the AAFP annual wellness visit coding guidance walks family physicians through the same distinction.

Why 99397 Denies Under Original Medicare

CPT 99397 is a preventive medicine service for an established patient aged 65 and older. Original Medicare does not cover 99397. Bill G0438 or G0439 instead, depending on the patient’s AWV history.

Billing a non-covered routine physical as a covered annual wellness visit CPT code is not a coding shortcut. Audit contractors look for that pattern specifically, and Section 21 covers the approved review topic that targets it.

Patients ask for their annual physical. Front desk staff schedule an AWV. Neither side explains the difference, and the complaint surfaces at checkout when the patient realizes no one listened to their heart.

12. Who Can Perform and Bill a Medicare Annual Wellness Visit

Medicare Part B covers an annual wellness visit when performed by a physician, a qualified non-physician practitioner, or a medical professional or team working under the direct supervision of a physician.

Eligible Billing Providers

• Physicians, MD or DO.
• Physician assistants.
• Nurse practitioners.
• Certified clinical nurse specialists.
• A medical professional or team, including health educators, registered dietitians, or nutrition professionals working under direct supervision.

What Clinical Staff Can and Cannot Do

Clinical staff may collect substantial portions of the AWV under incident-to rules with appropriate supervision. Direct supervision means the supervising provider is present in the office suite and immediately available, which is stricter than being reachable by phone.

Practices that run AWVs entirely on clinical staff without that presence carry real compliance exposure. The visit still happened. The supervision requirement still failed, and a reviewer reads the schedule to work out which provider was in the building that afternoon.

CMS has clarified one point that reshapes staffing models. When an AWV is furnished by a professional who does not have diagnosis and treatment within their scope of practice, meaning someone who cannot bill E/M services, that AWV cannot serve as the initiating visit for care management services.

Practices building a chronic care management program off AWV volume need that constraint before they design the staffing model. Build the program on a dietitian-run AWV workflow and the enrollment pathway closes behind you. Section 23 covers the program build.

13. Commercial Preventive Visit CPT Codes by Age: 99381 to 99397

Commercial and Affordable Care Act plans reimburse annual preventive visits under the CPT preventive medicine services family, not under Medicare G-codes. The code depends on two variables: whether the patient is new or established, and the patient’s age on the date of service.

New Patient Preventive Codes: 99381 to 99387

Code	Age range	Patient status
99381	Under 1 year	New patient
99382	1 to 4 years	New patient
99383	5 to 11 years	New patient
99384	12 to 17 years	New patient
99385	18 to 39 years	New patient
99386	40 to 64 years	New patient
99387	65 years and older	New patient

Established Patient Preventive Codes: 99391 to 99397

Code	Age range	Patient status
99391	Under 1 year	Established patient
99392	1 to 4 years	Established patient
99393	5 to 11 years	Established patient
99394	12 to 17 years	Established patient
99395	18 to 39 years	Established patient
99396	40 to 64 years	Established patient
99397	65 years and older	Established patient

Image asset: preventive-cpt-codes-by-age-99381-99397-chart-2026.png | Alt text: “Preventive medicine CPT codes 99381 through 99397 by patient age and new or established status.”

CPT 99395, 99396, and 99397: The Three Adult Codes Most Often Confused

CPT 99395 is a preventive medicine service for an established patient aged 18 to 39.

Patient Status: Established patient, seen by the practice within the previous three years.

Age Range: 18 to 39 years on the date of service.

What It Includes: Comprehensive history, age-appropriate examination, risk factor reduction counseling, and anticipatory guidance.

The Medicare Exception: Original Medicare does not cover 99395. Bill G0438 or G0439 instead, depending on the patient’s AWV history.

CPT 99396 is a preventive medicine service for an established patient aged 40 to 64.

Patient Status: Established patient, seen by the practice within the previous three years.

Age Range: 40 to 64 years on the date of service.

What It Includes: Comprehensive history, age-appropriate examination, risk factor reduction counseling, and ordering of age-appropriate screenings.

The Medicare Exception: Original Medicare does not cover 99396. Bill G0438 or G0439 instead, depending on the patient’s AWV history.

CPT 99397 is a preventive medicine service for an established patient aged 65 and older.

Patient Status: Established patient, seen by the practice within the previous three years.

Age Range: 65 years and older on the date of service.

What It Includes: Comprehensive history, age-appropriate examination, risk factor reduction counseling, and review of screening and immunization status.

The Medicare Exception: Original Medicare does not cover 99397. Bill G0438 or G0439 instead, depending on the patient’s AWV history.

Why These Codes Deny Under Original Medicare

These codes deny under Original Medicare because CPT preventive medicine services are statutorily excluded. The denial has nothing to do with a documentation gap, so an appeal will not recover the money no matter how complete the note is.

Bill the AWV G-code as the covered service and handle the non-covered preventive physical portion separately with appropriate patient notice. Payer rules differ once you leave Original Medicare, and Medicaid runs its own logic entirely, which is why Medicaid preventive visit billing needs a separate check before the claim goes out.

Age transitions catch practices every year. A patient who turns 65 between one preventive visit and the next moves from 99396 to 99397 for commercial coverage, and may move to the Medicare G-code family entirely once Part B starts. Carry the prior year’s annual wellness visit CPT code forward and the claim generates an age-mismatch denial.

14. Medicare Advantage, Medicaid, and Commercial: How AWV Rules Change by Payer

Annual wellness visit billing rules differ by payer type. Original Medicare, Medicare Advantage, Medicaid, and commercial plans each apply different code sets, different eligibility clocks, or both.

Payer type	Code family	Eligibility clock	Cost sharing
Original Medicare	G0402, G0438, G0439	Rolling 12-month period, resets on the first of the month	None when the provider accepts assignment
Medicare Advantage	G0402, G0438, G0439 in most plans	Often calendar year, varies by plan	Usually none, plan rules vary
Medicaid	Varies by state, G-codes or 99381 to 99397	Set by the state plan, EPSDT rules apply under 21	Varies by state
Commercial and ACA	99381 to 99397	Typically once per plan year	Usually waived as a preventive benefit

Medicare Advantage Uses a Different Eligibility Clock

Medicare Advantage plans generally accept G0438 and G0439 and follow the Medicare clinical framework. The operational difference sits in the eligibility clock, because many MA plans apply a calendar-year model rather than the rolling 12-month window Original Medicare uses.

Work the dates. A patient seen in April 2025 may become eligible again on January 1, 2026 under certain MA plans, against April 1, 2026 under Original Medicare. That is a full quarter of benefit window, and practices that apply one rule across a mixed panel either bill early and get denied or bill late and lose the visit.

Medicaid AWV Coverage Varies by State

Coverage varies by state. Some state Medicaid programs cover G0438 and G0439 directly with their own frequency rules and age restrictions. Others route adult preventive visits through the CPT preventive medicine family. For beneficiaries under 21, EPSDT requirements govern and the code set differs again.

Verify the state plan before assuming either code family applies. A rule that holds in one state fails in the one next door, and no national summary substitutes for the state manual.

Commercial Plans Use the CPT Preventive Family

Commercial and ACA plans use the 99381 to 99397 family, covered in full in Section 13. Practices running a single annual wellness visit CPT code workflow across a mixed payer panel generate denials on the non-Medicare portion, because the eligibility check has to include payer type alongside AWV history.

15. Annual Wellness Visit Documentation Requirements

Every annual wellness visit claim must be supported by documentation covering all required components. A missing component is grounds for denial on audit, regardless of what was clinically performed.

The Health Risk Assessment

The HRA is a patient-completed questionnaire capturing self-reported health status, psychosocial risks, behavioral risks including tobacco use and physical activity, activities of daily living, and instrumental activities of daily living. CMS does not mandate a specific form, though the tool must capture every required data element.

Practices that collect the HRA at check-in run behind all morning, because completion takes 10 to 15 minutes and the exam room clock starts anyway. Send it ahead of the visit and both the schedule problem and the documentation problem go away.

Cognitive and Depression Screening

CMS requires cognitive impairment detection through direct observation, patient or caregiver report, a brief validated screening tool, or some combination. No specific instrument is mandated. Commonly used tools include the Mini-Cog, MMSE, MoCA, and SLUMS.

Depression screening uses a standardized instrument such as the PHQ-2 or PHQ-9. Document the tool name and the result, not a note saying screening occurred. A reviewer who cannot identify the instrument treats the element as missing, and the whole annual wellness visit CPT code line goes back.

The Written Personalized Prevention Plan

The prevention plan is the centerpiece of the visit. It must include a tailored screening schedule, an immunization schedule, and a list of identified risk factors with recommended interventions. Functional limitations belong here too, and unsteady gait ICD-10 coding is where fall risk findings usually land on the diagnosis side.

Furnish the plan to the patient in writing, either as a printed copy or through the patient portal. Discussing recommendations verbally without providing written documentation does not meet the requirement, and a chart note describing the conversation will not close the gap.

What Auditors Look For

• A completed and signed Health Risk Assessment.
• Screening results with the tool names documented.
• A written individualized prevention plan furnished to the patient.
• Medication reconciliation.
• Provider signature with credentials.

Auto-populated notes that produce identical content across visits are a documented audit flag. A prevention plan that says the same thing for every patient in the panel is not a personalized prevention plan, and a reviewer reads it that way within about 30 seconds of opening the second chart.

16. ICD-10 Codes for Annual Wellness Visit Claims

CMS does not mandate a specific diagnosis code for annual wellness visit claims. Providers may report any diagnosis code consistent with the encounter, and Z00.00 is the code most commonly reported.

Z00.00 and Z00.01: The Primary Diagnosis Codes

ICD-10 code	Description	When to use
Z00.00	General adult medical examination without abnormal findings	Primary AWV diagnosis when screening results are normal
Z00.01	General adult medical examination with abnormal findings	Primary AWV diagnosis when screening identifies abnormalities
Z23	Encounter for immunization	When vaccines are administered during the visit
Z71.89	Other specified counseling	When counseling extends beyond standard AWV components

The Diagnosis Error That Denies AWV Claims

Leading the AWV claim line with a problem-oriented diagnosis is one of the most common causes of AWV denial. Put E11.9 for diabetes or I10 for hypertension in the primary position and the payer reads the encounter as problem-oriented, then denies the preventive code.

The AWV is a well visit. Lead with a Z00.0X code and let the chronic conditions follow in the secondary positions where they belong. AAFP coding guidance makes the same point for family practices.

Same-day billing changes the picture slightly. When a separately identifiable E/M service is billed on the same date, the problem-oriented diagnosis attaches to the E/M line rather than to the AWV line. Each line carries its own diagnosis pointer, and Section 17 covers the construction.

17. Billing an E/M Visit on the Same Day as an Annual Wellness Visit

A separately identifiable, medically necessary E/M service may be billed on the same date as an annual wellness visit. CMS instructs providers to report the additional service using 99202 through 99205 or 99211 through 99215 with modifier 25.

When a Separate E/M Is Billable

• The patient raises a new or worsening problem during the AWV.
• The provider evaluates and manages that problem beyond the scope of the preventive work.
• The documentation separates the two services.

A visit running long does not create an E/M. A distinct evaluation does. If the provider spent 15 extra minutes reassuring a patient about a screening result, that is still preventive work and it stays inside the AWV.

Modifier 25 Goes on the E/M Code

Modifier 25 goes on the E/M code. The annual wellness visit CPT code is reported without a modifier. Reversing the two is the single most common mechanical error on this combination, and it produces a bundling denial that looks like a coverage problem.

Can 99397 and G0439 Be Billed Together?

Under Original Medicare, no, because 99397 is statutorily excluded and both cannot be billed to Medicare as covered services. Bill the AWV as covered under G0439. The non-covered preventive physical portion becomes patient responsibility, handled with appropriate advance notice before the visit.

Under commercial coverage the question does not arise, because commercial plans do not use G0439. The pairing only becomes a question when a Medicare patient wants the full physical and the practice wants to capture both halves of the encounter.

Can 99214 and G0439 Be Billed Together?

Yes, when the E/M is significant and separately identifiable. Report G0439 without a modifier and 99214 with modifier 25. The note must show two distinct services with separate assessments, and CPT 99214 Medicare reimbursement covers what the E/M side is worth once it clears.

Auditors read for the phrase significant, separately identifiable, and billers rarely define it in the record. If a reviewer cannot point to two separate services in the note, modifier 25 will not survive appeal. The modifier 25 documentation standards that hold up on review are the ones written as two assessments, not one long paragraph.

Time-based E/M selection carries an extra trap. If the provider selected the E/M level by time, AWV time cannot count toward that total. Only the problem-oriented minutes count, and the note has to make the split visible.

Worked example: a 68-year-old presents for a subsequent AWV. During the visit the patient reports new chest tightness with exertion. The provider performs a cardiovascular evaluation, orders an ECG, and adjusts medication. Bill G0439 for the preventive service and 99214 with modifier 25 for the problem-oriented service, with the cardiac diagnosis pointed to the E/M line.

18. Add-On Codes You Can Bill With an Annual Wellness Visit

Several preventive and care management services may be billed alongside an annual wellness visit when the documentation supports each one separately. Each add-on carries its own frequency limit, modifier requirement, and bundling rule.

The Complete AWV Add-On Code Matrix

Code	Service	Rule that determines whether it pays
G0444	Depression screening	Bundled into G0402 and G0438. Separately billable only with G0439.
G0442	Alcohol misuse screening	Annual. Billable with the AWV when performed and documented.
G0443	Alcohol misuse counseling	Denies without a G0442 in the preceding 12 months.
G0447	Obesity counseling	Requires a BMI of 30 or above.
G0389	Abdominal aortic aneurysm screening	Pairs only with G0402. Not billable with an AWV.
G0136	Physical activity and nutrition assessment	Once every six months. Modifier 33 waives cost sharing.
99497	Advance care planning, first 30 minutes	Requires modifier 33 on the same AWV claim to waive cost sharing.
99498	Advance care planning, each additional 30 minutes	Add-on to 99497. Same modifier logic applies.
99406, 99407	Smoking cessation counseling	Time-tiered. Document counseling minutes separately from AWV time.
G0513, G0514	Prolonged preventive service	G0513 covers 30 minutes beyond the typical duration. G0514 covers each additional 30 minutes.
99483	Cognitive assessment and care planning	Cannot be billed on the same date as the AWV. Requires a separate visit.

Smoking cessation is the row practices skip most often. The counseling happens during the wellness conversation, the minutes stay out of the note, and the smoking cessation counseling codes miss the claim.

Every add-on in that table rides on the same claim as the annual wellness visit CPT code, so the base code has to be right before any of them pay. Fix the G-code first, then chase the add-ons.

G0444: The Depression Screening Rule Most Practices Miss

Depression screening is a required component of G0402 and G0438, so G0444 is bundled into both and cannot be billed separately with either. Depression screening is not bundled into G0439.

When screening is performed and documented with a standardized tool during a subsequent AWV, G0444 is separately billable. Practices that never bill it lose the amount on every subsequent AWV in the panel, which across a 400-patient Medicare panel adds up to a number worth pulling.

G2211 With G0438 and G0439

G2211 is billable with modifier 25 on the same date as G0438 or G0439, effective January 1, 2025. No hedging required on this one. The rule is published and it is current.

The CY 2026 Physician Fee Schedule final rule expanded G2211 to home and residence E/M visits, 99341 through 99345 and 99347 through 99350, in addition to office and outpatient E/M. The G2211 add-on billing rules cover which base codes accept it.

One caveat. Systematic G2211 application to every encounter regardless of clinical context is a documented statistical outlier pattern in audit selection, so the add-on belongs on visits where the longitudinal relationship is real and visible in the note.

G0136 in 2026: What the Descriptor Change Means

G0136 changed descriptors on January 1, 2026, and charge capture templates across the country still carry the old one. The code number stayed the same, which is why the mismatch goes unnoticed for months.

Descriptor through December 31, 2025: Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes, not more often than every 6 months.

Descriptor effective January 1, 2026: Administration of a standardized, evidence-based assessment of physical activity and nutrition, 5-15 minutes, not more often than every 6 months.

CMS proposed deleting G0136 and, after comment, retained it with the revised descriptor. G0136 remains an optional additional element of the AWV with additional payment and no beneficiary cost sharing when billed with modifier 33 on the same AWV claim. G0136 also remains on the Medicare Telehealth Services List.

Charge capture templates, smart phrases, and coding cheat sheets built in 2024 or 2025 still describe G0136 as an SDOH assessment. Bill a physical activity and nutrition code while the note documents only social needs and you have a service mismatch, which surfaces on post-payment review rather than at adjudication.

19. FQHC, RHC, and Telehealth Annual Wellness Visit Billing

Federally Qualified Health Centers bill annual wellness visits using HCPCS code G0468, which represents an FQHC visit that includes an IPPE or an AWV. FQHCs are paid under the Prospective Payment System rather than the Physician Fee Schedule.

G0468: The FQHC Visit Code

Report G0468 alongside the standard G-code. An FQHC furnishing an IPPE bills G0402 plus G0468, and the standard AWV codes still appear on the claim for tracking purposes.

One detail rarely makes it into AWV coding guides. The FQHC PPS per-diem rate is adjusted by a factor of 1.3416 when the FQHC furnishes care to a new patient or provides an IPPE or AWV, and only one such adjustment applies per day, per the Medicare Claims Processing Manual, Chapter 9.

Rural Health Clinic Considerations

Rural Health Clinics follow a different payment methodology from both FQHCs and physician offices. In both FQHC and RHC settings, the AWV must be furnished by a practitioner meeting the facility’s visit definition: physician, nurse practitioner, physician assistant, or certified nurse midwife.

Auxiliary staff may complete elements under supervision, though the qualifying practitioner has to be involved in the encounter. A visit assembled entirely by support staff does not meet the facility visit definition, whatever the chart says afterward.

Billing an AWV Furnished by Telehealth

Medicare pays for G0438 and G0439 when furnished via telehealth, and the CMS Medicare Wellness Visits page carries the current coverage position. Apply the current telehealth modifier and telehealth place of service requirements to the claim.

Under CMS guidance, expanded geographic and originating site flexibility runs through December 31, 2027, with policy changes beginning January 1, 2028. Verify the current telehealth list before submitting, because statutory extensions have moved repeatedly and a lapsed flexibility denies quietly.

Do not carry physician-office AWV billing rules into an FQHC or RHC workflow. The payment methodology differs, the claim construction differs with it, and a biller trained on office claims will build the FQHC claim wrong on the first try.

20. Annual Wellness Visit Denial Codes and How to Resolve Them

Annual wellness visit denials cluster into three patterns. Each pattern carries a distinct claim adjustment reason code and a distinct resolution path.

Code	What it means	Typical AWV cause	Resolution
CARC 119 with RARC N130	Benefit maximum for this time period or occurrence has been reached	Frequency conflict, claim submitted before the eligible date	Verify the eligible date and rebill after the first of the eligible month
CO-97	Service included in the payment for another already-adjudicated service	Bundling, often a missing modifier 25 on the same-day E/M or a bundled add-on such as G0444 with G0438	Correct the modifier or remove the bundled add-on, then resubmit
CO-236	Procedure or procedure and modifier combination not compatible	Reported on advance care planning plus AWV plus a high-level E/M	Review modifier 33 and modifier 25 placement across all three lines

CARC 119: The Frequency Denial

The frequency denial is the most common AWV denial, and the cause is usually a scheduling artifact rather than an annual wellness visit CPT code error. The claim went out before the first day of the eligible month, or a prior AWV was furnished by another practice and never appeared in the local record.

Section 9 carries the timing rule that prevents it. The fix is a MAC portal check before the visit, not an appeal after it, and CARC-based denial recovery work starts by separating the two causes before anyone drafts anything.

CO-97: The Bundling Denial

Two distinct causes hide behind one code. The same-day E/M was submitted without modifier 25, so the payer bundled it into the preventive service. Or an add-on that is bundled into the base code was billed separately, most commonly G0444 with G0438.

Neither one is recoverable by resubmitting the same claim. The first needs a corrected claim with modifier 25 on the E/M line. The second needs the add-on removed, because the payment for it already sits inside the base code.

CO-236 and the ACP Combination

CO-236 appears on the advance care planning combination. Modifier 33 belongs on the ACP code when billed with the AWV. Modifier 25 belongs on the E/M. Reverse them, or omit one, and the payer returns an incompatibility.

How to Appeal an AWV Denial

1. Identify the CARC and RARC pair from the ERA rather than the paper remit summary.
2. Determine whether the denial is administrative or documentation-based.
3. Verify eligibility history through the MAC portal before drafting anything.
4. Correct and resubmit if administrative, or file a redetermination with the documentation if not, using payer-specific appeal construction for the format that payer accepts.
5. Track the pattern rather than the individual claim.

That last step is where the money is. A frequency denial repeating across three providers is a scheduling workflow problem, and appealing each one individually fixes none of them. Section 21 covers what happens when the pattern goes unaddressed long enough for a contractor to notice.

One more construction detail worth checking on same-day institutional claims: only the practitioner or the facility is paid for a same-day AWV, not both. The CMS editing update for the annual wellness visit spells out how the Common Working File edits handle it.

Frequency denials rarely arrive one at a time. When CARC 119 shows up on preventive claims across multiple providers, the cause is usually sitting in the scheduling workflow rather than in the coding. A denial pattern review will show you which one it is.

21. AWV Audit Risk: RAC Topics and the 24.5% Overpayment Rate

Annual wellness visit claims are an approved Recovery Audit Contractor review topic. CMS approved RAC topic 0176, Annual Wellness Visit: Incorrect Coding, on August 28, 2025, as a complex review applying to all A and B Medicare Administrative Contractors.

Approved RAC Topic 0176

The CMS approved RAC audit topic specifies three claim conditions, and the affected codes are G0402, G0438, and G0439. Complex review means the contractor requests records before making a determination.

• G0402 may not be billed more than 12 months after the effective date of first Part B coverage, or more than once in a lifetime.
• G0438 may not be billed more than once in a lifetime.
• G0439 may not be billed within 12 months of a prior G0438 or G0439.

A second, older topic sits alongside it. RAC topic 0077, approved January 9, 2018, is an automated review targeting an AWV billed sooner than 11 whole months following the IPPE. Automated means no records request arrives first. The recoupment shows up on the remittance.

The Six Most Common AWV Billing Errors

According to the CMS provider compliance tips for annual wellness visits, citing the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the overpayment rate for annual wellness visits was 24.5%, with a projected overpayment of approximately $307.5 million. Most of that figure traces to incomplete documentation rather than fraud.

1. Billing G0438 more than once per patient lifetime.
2. Missing Health Risk Assessment documentation in the record.
3. Billing before the eligible date.
4. Using a problem-oriented primary diagnosis.
5. Omitting modifier 25 on the same-day E/M.
6. Failing to bill G0444 separately with G0439.

That sixth item belongs on the list for a reason. Five of the six cost the practice money through denial or recoupment. The sixth costs money through revenue the practice earned and never captured, and the annual wellness visit CPT code family produces both failures in roughly equal measure.

22. 2026 Annual Wellness Visit Reimbursement Rates

Annual wellness visit payment is calculated by multiplying the code’s relative value units by the applicable conversion factor and the geographic practice cost index for the locality.

How AWV Payment Is Calculated in 2026

CY 2026 established two conversion factors for the first time, and which one applies depends on the practice’s Quality Payment Program participation status.

Participation status	CY 2026 conversion factor	Change from CY 2025
Qualifying APM participant	$33.5675	Increase of 3.77%
Non-qualifying participant	$33.4009	Increase of 3.26%

Both figures come from the CY 2026 Medicare Physician Fee Schedule final rule, CMS-1832-F, effective January 1, 2026. Run the practice’s status before quoting either number to a physician, because the gap between them compounds across a full Medicare panel.

Code	Service	2026 national payment amount
G0402	Initial Preventive Physical Examination	[Populate from the current PFS national payment amount file]
G0438	Initial Annual Wellness Visit	[Populate from the current PFS national payment amount file]
G0439	Subsequent Annual Wellness Visit	[Populate from the current PFS national payment amount file]
G0468	FQHC visit including IPPE or AWV	Paid under the FQHC Prospective Payment System, not the PFS

Methodology: rates above are national payment amounts drawn from the CMS Physician Fee Schedule national payment amount file. Record the file release and effective date here at publication. Locality adjustment moves every figure, so verify in the CMS Physician Fee Schedule Look-Up Tool before quoting a number to a provider.

Why Published AWV Rates Disagree

Published rates for the same annual wellness visit CPT code disagree across sources, and the range spans roughly $120 to $180 depending on where you look. Three causes explain the spread.

• Sources cite different years without saying which.
• Sources mix facility and non-facility rates in the same table.
• Sources report national averages without noting that locality adjustment moves the number materially.

Picking a number does not resolve the disagreement. Publishing the methodology and pointing at the lookup tool does, which is why the table above shows the basis rather than a single authoritative-sounding figure.

G0438 reimburses more than G0439 because the initial visit builds the baseline documentation. Practices that default to G0439 for patients who have never had an AWV lose that differential on every occurrence, and the loss compounds quietly across a Medicare panel because the claim still pays.

23. Building an Annual Wellness Visit Program That Captures Every Eligible Patient

Annual wellness visit revenue is captured through workflow. The annual wellness visit CPT code selection is the last step in a process that begins at scheduling.

Before the Visit

• Confirm Part B eligibility and the effective date.
• Check the last AWV or IPPE date through the MAC portal.
• Calculate the earliest eligible date as the first day of the month, 12 months out.
• Send the Health Risk Assessment ahead of the appointment.
• Set patient expectations about what the visit does and does not include.

During the Visit

• Collect and review the completed Health Risk Assessment.
• Update history, medications, and the provider list.
• Perform and document cognitive and depression screening with the tool names recorded.
• Assess functional ability and fall risk.
• Create or update the written prevention plan.
• Identify patients who may qualify for care management programs.

After the Visit

• Furnish the prevention plan to the patient in writing.
• Close open screening gaps, starting with colorectal screening code selection.
• Schedule follow-up services.
• Verify the correct G-code against the patient’s actual history rather than the prior year’s claim.
• Route eligible patients into care management enrollment.

Using the AWV to Identify Care Management Candidates

The AWV is the most efficient encounter for identifying care management candidates, because the provider is already reviewing chronic conditions, medications, functional limitations, and risk factors. Those are the same data points that determine eligibility for chronic care management codes, principal care management, and remote physiologic monitoring.

Discharged patients follow a parallel path, and transitional care management billing rules govern the 30-day window after an inpatient stay. An AWV scheduled inside that window needs both sets of rules checked before either claim goes out.

Carry the constraint from Section 12 into the design. When the AWV is furnished by a professional who cannot bill E/M services, that AWV cannot serve as the initiating visit for care management. Settle the staffing model before building the program on top of it.

A large share of eligible Medicare patients never receive an AWV in a given year, despite zero cost sharing and no prior authorization requirement. The gap is rarely clinical. Scheduling, eligibility tracking, and patient communication account for most of it, which puts the fix inside full revenue cycle management rather than inside the exam room.

24. Annual Wellness Visit CPT Code FAQs

What is the CPT code for an annual wellness visit?

Medicare bills the annual wellness visit CPT code family as HCPCS G0438 for the initial visit and G0439 for each subsequent visit. G0402 covers the Welcome to Medicare visit during the first 12 months of Part B. Commercial plans use CPT 99381 through 99397 by patient age and status.

Is CPT 99397 an annual wellness visit?

CPT 99397 is a preventive medicine service for an established patient aged 65 and older, which describes a comprehensive physical rather than a Medicare wellness visit. Original Medicare does not cover 99397. Bill G0438 or G0439 instead, depending on whether the patient has had a prior AWV.

Is CPT 99396 a wellness visit?

CPT 99396 is a preventive medicine service for an established patient aged 40 to 64 under commercial coverage. Original Medicare does not cover 99396. For a Medicare beneficiary in that age band who qualified through disability, bill G0438 or G0439 based on AWV history.

What is CPT code 99395?

CPT 99395 covers a preventive medicine visit for an established patient aged 18 to 39. The service includes a comprehensive history, an age-appropriate examination, and risk factor reduction counseling. Original Medicare does not cover 99395, and G0438 or G0439 applies for Medicare beneficiaries.

Can I bill G0439 and 99397 together?

Under Original Medicare, G0439 and 99397 cannot both be billed as covered services, because 99397 is statutorily excluded. Bill G0439 as the covered AWV and treat the non-covered physical portion as patient responsibility with advance notice. Commercial plans do not use G0439, so the pairing does not arise there.

Can I bill for an annual wellness visit with an E&M service?

Yes, when the E/M is significant and separately identifiable from the preventive work. Report the AWV G-code without a modifier and the E/M code with modifier 25. CMS names 99202 through 99205 and 99211 through 99215 as the E/M codes reportable alongside the AWV.

What is the ICD-10 code for a Medicare annual wellness visit?

Z00.00 is the code most commonly reported for a Medicare annual wellness visit when screening results are normal. Z00.01 applies when screening identifies abnormal findings. CMS does not mandate a specific diagnosis code, though leading the claim line with a problem-oriented diagnosis triggers denial.

Does Medicare pay 100% of an annual wellness visit?

Medicare pays the full allowed amount for G0438 and G0439 with no copayment and no deductible when the provider accepts assignment. Cost sharing applies if a separately identifiable E/M service is billed the same day, or if a non-covered service gets added to the encounter.

What are the three types of Medicare wellness visits?

Medicare covers three preventive visit types. The Initial Preventive Physical Examination, billed with G0402, runs during the first 12 months of Part B. The Initial Annual Wellness Visit, billed with G0438, is available once per lifetime. The Subsequent Annual Wellness Visit, billed with G0439, repeats every 12 months.

How often can G0439 be billed?

G0439 is billable once per 12-month period following a prior G0438 or G0439. Eligibility returns on the first day of the month in which the 12-month period ends. A visit on March 15, 2025 makes the patient eligible again on March 1, 2026 rather than March 15.

What are the CMS annual wellness visit guidelines for 2026?

CMS guidelines for 2026 keep G0438 at once per beneficiary lifetime and G0439 at once per 12-month period. G2211 remains billable with modifier 25 alongside both codes. G0136 changed on January 1, 2026 from a social determinants of health assessment to a physical activity and nutrition assessment.

What is the difference between CPT codes 99396 and 99397?

Age separates them. CPT 99396 covers established patients aged 40 to 64, and CPT 99397 covers established patients aged 65 and older. Both are preventive medicine services under commercial coverage. Original Medicare covers neither code, and G0438 or G0439 applies instead based on AWV history.

AWV coding gets simple once the eligibility check runs before the visit instead of after the denial. If preventive claims are denying at your practice and the pattern has not been traced yet, the scheduling workflow is usually where it starts. ClaimMax RCM runs a free denial audit against your own claim file to find the root cause.

Practices running high Medicare volume in primary care see this pattern more than any other specialty, because the Medicare panel is large enough for one scheduling error to repeat hundreds of times a year.