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Billing Reference

AWV Billing and CPT Codes: A Comprehensive Reference

A Medicare-focused claim-readiness reference for billing teams, practice managers, clinicians, pharmacists, and revenue-cycle staff.

The preventive-visit code sequence

G0402: IPPE

The Initial Preventive Physical Examination is a one-time benefit available only within the first 12 months after Medicare Part B coverage begins.

G0438: Initial AWV

Report for the patient's first AWV. CMS says not to bill G0438 within 12 months after G0402; G0438 is not based on whether the patient is new to the practice.

G0439: Subsequent AWV

Report after the first AWV, outside the rolling 12-month frequency window. CMS limits G0438 or G0439 to once in a 12-month period.

Do not substitute G0406

G0406 is a limited follow-up inpatient telehealth consultation code, not an IPPE or AWV code. G0402 is the IPPE. Correct any template or crosswalk that says otherwise.

Frequency and eligibility controls

  • Verify the Part B effective date and paid-claims history before selecting a code.
  • G0402 is one time and limited to the first 12 months of Part B.
  • G0438 is the first AWV and is generally once in a lifetime.
  • G0439 is subsequent; do not bill it within 12 months of G0438 or G0439.
  • Do not bill G0438 or G0439 within 12 months after G0402.
  • Use the service date and confirm exact eligibility through current Medicare systems and payer guidance; do not infer eligibility from the calendar year or local EHR alone.

Add-on and same-day services

Advance care planning: 99497 and 99498

ACP is voluntary and time based. CMS's current MLN fact sheet maps 16-45 minutes to 99497, 46-75 minutes to 99497 plus one unit of 99498, and later increments according to the published time table. Document that participation was voluntary, advance directives were explained, who participated, and ACP-only time. Do not overlap that time with another time-based service.

CMS waives ACP deductible and coinsurance when ACP is delivered on the same day by the same AWV provider and billed with modifier 33 on the same AWV claim. If those conditions are not met—or the AWV is denied for frequency—the cost-sharing result differs. Verify the claim relationship before using modifier 33.

Separate E/M and modifier 25

CMS may pay a same-day office or outpatient E/M when it is significant, separately identifiable, medically necessary, and supported apart from the AWV. Append modifier 25 to the E/M code, not the AWV. A diagnosis mentioned during prevention planning does not by itself establish a separate E/M.

Other preventive services

Check each service's current coverage, frequency, practitioner, documentation, modifier, and cost-sharing rules. Do not assume an AWV component is separately payable.

Current G0136 description

CMS currently describes G0136 as administration of a standardized, evidence-based physical activity and nutrition assessment, 5-15 minutes, not more often than every 6 months. It is not the AWV HRA administration code. Its descriptor changed from the prior SDOH risk-assessment description, so verify current CMS guidance and code-year files rather than reusing older templates.

Diagnosis and supporting documentation

CMS requires a diagnosis code on an AWV claim but does not require a specific AWV diagnosis. Choose a code consistent with the examination and documentation; do not add conditions merely to support payment.

Core AWV evidence

  • Eligibility and prior-utilization verification
  • Completed HRA and applicable first or subsequent AWV elements
  • Measurements and assessment results
  • Written screening schedule, risk list, personalized advice, and referrals
  • Rendering and billing practitioner information and authenticated record

Separate-service evidence

  • Distinct problem-oriented E/M work for modifier 25
  • ACP voluntariness, participants, discussion, and non-overlapping time
  • G0136 tool, duration, frequency, and claim relationship
  • Telehealth modality, place of service, modifiers, and measurement sources
  • Any payer- or setting-specific supervision documentation

Practical billing-readiness checklist

The source design proposed 20 automated rules. CMS does not mandate a 20-rule engine, and this is not a claim that FairPath currently provides one. Use the underlying questions as a human or system-assisted pre-claim review:

  1. Is the patient outside the first 12 months of Part B for an AWV?
  2. Is the last IPPE outside the exclusion window?
  3. Is the last AWV outside the rolling 12-month window?
  4. Does G0438 versus G0439 match claims history?
  5. Is the required HRA complete?
  6. Are required measurements documented?
  7. Is cognition addressed?
  8. Are history and provider lists established or updated as required?
  9. Is the screening schedule complete?
  10. Are risks, conditions, and interventions documented?
  11. Are personalized advice and referrals documented?
  12. Was opioid review completed when applicable?
  13. Was SUD risk addressed?
  14. Is a consistent diagnosis code present?
  15. Is the record authenticated by the responsible practitioner?
  16. If ACP is billed, does documented time support the units?
  17. Does ACP documentation support the service?
  18. If modifier 33 is used, are same-day, same-provider, same-claim conditions met?
  19. If G0136 is billed, are the current descriptor, duration, frequency, and claim conditions met?
  20. If E/M is billed, is distinct medical necessity documented and modifier 25 correctly applied?

Claim packet and audit trail

Retain a coherent packet tying the claim to the clinical record: code selection and eligibility result, date and mode of service, diagnosis, rendering and billing provider, HRA, component summary, measurements, screening schedule and prevention plan, authentication, add-on documentation, and claim outcome. Preserve the submitted version and record corrections or denials as later events rather than obscuring what was originally sent.

Common errors

  • G0438 despite a prior AWV, or G0439 inside the frequency window
  • G0406 substituted for G0402
  • Missing HRA, prevention plan, or required component evidence
  • ACP reported at unsupported time or with overlapping time
  • Modifier 33 used without the required AWV claim relationship
  • Modifier 25 used without a separately identifiable E/M
  • G0136 labeled as HRA administration or carried forward from an obsolete descriptor
  • Telehealth delivery treated as permission to omit required content

Sources (public)

  1. CMS Medicare Wellness Visits overview
  2. CMS Annual Wellness Visit components and billing
  3. CMS Initial Preventive Physical Exam
  4. MLN Medicare Preventive Services
  5. MLN Advance Care Planning
  6. CMS Job Aid 6130: G0406
Disclaimer: This operational reference is not legal, coding, or reimbursement advice and does not guarantee coverage or payment. Confirm current CMS, MAC, payer, CPT, scope-of-practice, licensure, and telehealth rules for the date and setting of service.

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