HCPCS Code G0438: Medicare Initial Annual Wellness Visit

HCPCS code G0438 is used to bill a Medicare patient’s first Annual Wellness Visit (AWV). 

This visit focuses on creating a personalized prevention plan based on the patient’s health risks, medical history, and screening needs. 

When the provider accepts assignment, Medicare Part B covers the visit in full with no copay or deductible for the patient.

The official CMS description is: “Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit.” 

G0438 is an HCPCS Level II code and should not be confused with standard CPT preventive visit codes (99381–99397), which Medicare does not cover for routine physicals.

This guide explains eligibility, coverage details, required components, billing rules, and common mistakes to avoid when using G0438.

How Does G0438 Differ From G0402 and G0439?

G0438 sits between two other Medicare wellness codes. The right code depends on when the patient enrolled in Medicare and which visits they have already had. Each code covers a different stage of preventive care.

• G0402 (Initial Preventive Physical Examination) is the “Welcome to Medicare” visit. Patients can only get this during their first 12 months of Part B enrollment. It is a one-time benefit. It includes baseline vital signs, a vision check, depression screening, and an overview of Medicare’s preventive benefits. If the patient misses this 12-month window, the G0402 benefit is gone for good.
• G0438 (Initial Annual Wellness Visit) opens up after the patient has had Part B for at least 12 months. Whether or not the patient did the G0402, they still need to complete G0438 as their first AWV. This visit builds the full set of baseline records. It creates the HRA and PPPS that all future visits will update.
• G0439 (Subsequent Annual Wellness Visit) covers every AWV after the first G0438. It can be billed once every 12 months. Instead of creating new baseline records, G0439 updates the existing HRA, medical history, screening schedule, and prevention plan.

The payment gap between these codes is large. G0438 pays about 50% more than G0439 because setting up baseline records takes more time and work than updating them. Practices that bill G0439 by mistake for a patient’s first AWV lose real money on every affected claim.

Feature	G0402 (IPPE)	G0438 (Initial AWV)	G0439 (Follow-Up AWV)
Common Name	Welcome to Medicare	First Annual Wellness Visit	Yearly Follow-Up Wellness Visit
How Often	Once per lifetime	Once per lifetime	Once every 12 months
Who Qualifies	First 12 months of Part B	After 12+ months of Part B	12 months after last G0438 or G0439
Physical Exam Included	Yes (limited)	No	No
HRA Included	Yes	Yes (full version)	Yes (update only)
PPPS Included	No	Yes (created new)	Yes (updated)
2026 Average Payment	~$175	~$174	~$138
Memory Check Required	No	Yes	Yes
Vision Check Required	Yes	No	No

Timing example: Maria signs up for Medicare Part B on March 1, 2025. From March 1, 2025 through February 28, 2026, she can only get G0402. Starting March 1, 2026, she can get G0438. Say she gets G0438 on April 15, 2026. She can then get G0439 starting April 1, 2027.

Medicare uses the first day of the same calendar month the next year, not the exact one-year date. If Maria skips the Welcome to Medicare visit entirely and shows up for the first time in June 2027, the right code is still G0438. She has never had an initial AWV, no matter how much time has passed.

What Are the Medicare Coverage and Eligibility Requirements for G0438?

Medicare Part B covers G0438 at no cost to the patient when three conditions are met. The patient must have active Part B coverage. They must have been enrolled for more than 12 months. And they must not have had an IPPE (G0402) or any AWV within the past 12 months.

Patient Eligibility Rules for G0438

The patient needs active Medicare Part B. Part A alone does not count. The enrollment period must be longer than 12 full months before the G0438 visit date. If the patient is still in their first 12 months of Part B, bill G0402 instead. Billing G0438 during this window is the top cause of AWV claim denials.

Medicare also checks whether a G0402, G0438, or G0439 was paid in the prior 12 months. If any of those codes were paid during that time, the new claim will be denied. The denial message says the patient hit their benefit limit for the period. Medicare counts the 12-month gap by calendar month. A patient who had an AWV on June 30 of one year becomes eligible again on June 1 of the next year.

Who Can Do Bill the Initial AWV Code G0438

Eligible providers who can perform and bill G0438:

• Physicians (MD or DO)
• Physician Assistants (PA)
• Nurse Practitioners (NP)
• Certified Clinical Nurse Specialists (CNS)

A team of medical staff (like health educators, dietitians, or other licensed practitioners) can also handle the AWV under a physician’s direct watch.

This setup lets clinical staff take care of most of the HRA, measurements, and paperwork. The physician or qualified provider then reviews the results and signs off on the prevention plan. The billing provider must have an active NPI number.

Frequency Limits and Compliance Of G0438

G0438 can be billed exactly once per patient per lifetime. Medicare’s claims system flags and rejects repeat G0438 claims on its own. Practices should check a patient’s claims history or use the HETS (Health Eligibility and Transaction System) portal before booking an initial AWV. This confirms the patient has not already had one from another provider.

Filing too many G0438 claims draws attention from Recovery Audit Contractors (RACs). Data from 2024 Medicare Fee-for-Service reports showed that the AWV overpayment rate was 24.5%. The total projected overpayment reached $307.5 million. This makes AWV billing a top audit target.

What Documentation Is Required for G0438?

Good records are the single biggest factor in getting G0438 claims paid and passing audits. If any required piece is missing, Medicare can deny the claim or take back the money after payment.

How to Bill G0438 Correctly

Send G0438 on a CMS-1500 claim form (or its digital version, the 837P) with the right place of service code. For office visits, use POS 11. For telehealth visits (Medicare allows AWVs by video), use POS 02 or POS 10 based on where the patient is.

Claim Steps and Modifiers

G0438 usually needs no modifier when billed on its own. But if you also handle a separate medical problem during the same visit, bill the office visit code (99202 through 99215) with modifier -25. This tells Medicare you did a separate, clearly different service. The AWV stays fully covered. The office visit part is subject to the patient’s normal copay and deductible.

When billing Advance Care Planning (99497) on the same day as the AWV, add modifier -33 (Preventive Services). This waives the patient’s share of the cost for that service.

Starting in 2025 and going through 2026, providers can also bill G2211 (visit complexity add-on) with G0438. This applies when the patient has an ongoing tie with the provider for a hard-to-manage or serious condition. Adding G2211 raises the average G0438 payment from about $173 to $189.

ICD-10 Diagnosis Codes for the AWV

CMS does not require one exact diagnosis code for AWV claims. The usual choice is Z00.00 (general adult medical exam without abnormal findings) as the main diagnosis. If the provider finds something abnormal during the visit, switch to Z00.01 and list the specific findings as added diagnoses.

Here is the key rule: do not put a problem-based main diagnosis like E11.9 (diabetes) or I10 (high blood pressure) on the AWV claim. Medicare will likely deny it because AWVs count as preventive visits, not problem visits. Problem codes go on the separate office visit claim if you file one with modifier -25.

Common Billing Mistakes and How to Fix Them

• Billing G0438 when the patient is in their first 12 months of Part B: This is the most common denial trigger. Use G0402 during that window instead.
• Billing G0438 for a patient who already had one: Always check claims history first. Use the CMS HETS portal or your EHR’s eligibility tool.
• Using G0439 instead of G0438 for the first AWV: This costs the practice 25% to 50% less payment per claim and creates coding errors that draw audits. Run a report comparing your G0438 and G0439 numbers. If G0438 shows up less often than G0402, something is wrong in your coding process.
• Sending the claim without a complete PPPS: The prevention plan is not optional. Without it, the whole claim fails records standards.

What to Do About Denied Claims

When a G0438 claim is denied, read the denial reason code first. Common cases include: Reason Code 149 (benefit limit hit, meaning G0438 was already paid for this patient), Code 96 (charges not covered, often tied to eligibility issues), and Code 4 (modifier needed or wrong modifier used).

For eligibility denials, check Part B enrollment length and look for past AWV claims. If the denial was wrong, send a corrected claim with backup records. For benefit-limit denials on a patient who truly never had a prior G0438, contact the Medicare Administrative Contractor (MAC) with proof that no earlier initial AWV was billed.

Think about getting an Advance Beneficiary Notice (ABN) before the visit if you cannot confirm the patient’s AWV history. The ABN protects both the provider and patient if the claim gets turned down.

G0438 Reimbursement Rate and Fee Schedule

The 2026 national average Medicare payment for G0438 is about $174. Payment is based on RVUs, the conversion factor, and geographic adjustments. Rates vary by location and setting, with office services typically reimbursed slightly higher than hospital outpatient visits.

Always check your MAC and local fee schedule. Verify rates using your Medicare Administrative Contractor (MAC), local GPCI adjustments, and payer contracts, especially for Medicare Advantage plans.

Which Additional Codes Can Be Billed With G0438?

Several add-on codes pair with G0438 for extra preventive services done during the same visit. Each code has its own rules. Some are limited to certain AWV types.

Screening and Counseling Add-On Codes

• G0442: Annual alcohol misuse screening: A 5- to 15-minute screening with a standard tool. You can bill it with both G0438 and G0439. It must be done before any alcohol counseling (G0443) can go through.
• G0443: Alcohol misuse counseling: Covers a 15-minute face-to-face counseling session for patients who test positive on G0442. A G0442 claim must exist in the prior 12 months.
• G0447: Obesity counseling: A 15-minute session on behavior change for patients with a BMI of 30 or higher. Can be billed with IPPE or AWV codes. Includes diet review and lifestyle change tips.
• G0444: Annual depression screening: A 5- to 15-minute screening with a standard tool. Important limit: G0444 can only be billed with follow-up AWVs (G0439). It is treated as part of G0438 and will be denied if billed with the initial AWV. Many practices miss this rule.
• G0389: Abdominal aortic aneurysm screening: An ultrasound screening for at-risk patients. Key limit: G0389 can only be billed with G0402 (the Welcome to Medicare visit). It is not allowed with G0438 or G0439.

Extended and Extra Service Codes

• CPT 99497: Advance Care Planning (first 30 minutes): Covers a face-to-face talk about advance directives and future care wishes. When billed the same day as the AWV with modifier -33, the patient’s copay and deductible are waived. CPT 99498 covers each extra 30-minute block. There is no yearly limit on how often you can bill ACP. But each session must show changes in the patient’s health or care wishes.
• G0513: Prolonged preventive services (first 30 minutes past normal visit time): Use this add-on when the AWV runs much longer than usual. This may happen with patients who have many long-term conditions or memory problems that need extra counseling. G0514 covers each further 30-minute block past G0513. Write down the time spent and the clinical reason for the longer visit.
• G0136: Physical Activity and Nutrition Risk Assessment: On January 1, 2026, CMS changed what this code means. It used to cover Social Determinants of Health (SDoH) checks. Now it covers a standard, evidence-based review of physical activity and nutrition, lasting 5 to 15 minutes. You can bill it once every six months. When billed the same day as an AWV, CMS waives the patient’s copay and deductible. Use modifier -33 on the AWV claim. The twice-a-year billing cycle makes G0136 one of the most useful add-ons for 2026. It creates a second paid visit within the yearly AWV cycle.
• G2211: Visit complexity add-on: Available since 2025 and still active in 2026, this code goes with G0438 and G0439 when the provider has an ongoing care role for a complex or serious condition. The national average payment is about $16. Combined with G0438, the total reaches roughly $189.

G0438 Coding Mistakes That Lead to Denials, Underpayments, and Audit Risk

Incorrect code selection, incomplete prevention plans, weak documentation, and misuse of AWV visits can trigger denials, reduce reimbursement, or lead to Medicare audit exposure.

• Billing G0438 vs. G0439 by Mistake: Using G0439 for first-time AWVs leads to denials or reduced payment. Always verify prior AWV history and audit coding trends to prevent revenue loss.
• Missing Required PPPS Components: Failing to document a complete prevention plan risks audit failure. Include screening schedules, risk factors, interventions, and confirmation the patient received the plan.
• Weak Documentation That Triggers Audits: Copied notes, vague counseling, and missing details raise red flags. Record tools used, patient responses, decisions made, and reasons for skipped screenings.
• High AWV Volume and Audit Exposure: Unusual billing patterns increase audit risk. Avoid duplicate initial visits, improper frequency, and billing patients without active Medicare Part B eligibility.
• Confusing AWV with a Physical Exam: Treating AWV like a physical leads to denials or patient charges. Use AWV-specific templates and bill separately for medically necessary exams with proper modifiers.

Final Words

HCPCS code G0438 is a high-value preventive service that helps patients, practices, and the broader Medicare system. Getting it right starts with checking patient eligibility, making sure every required piece is in the records, and knowing the strict once-per-lifetime rule.

Check CMS updates each year to catch coding changes. Build AWV-only templates in your EHR. Train every team member who touches scheduling, records, or billing on the differences between G0402, G0438, and G0439. Practices that get these basics right avoid denials, lower audit risk, and turn preventive visits into a solid base for care management and value-based revenue.