Master the 2026 Annual Wellness Visit Coding & Billing Guide

By Elizaveta Bannova, Billing Department, WCH; Educational Officer, AAPC

Why This Matters

The Annual Wellness Visit is one of the most underutilized preventive services in primary care — and one of the most valuable. It carries no cost to the patient, generates direct reimbursement for the provider, and creates a structured opportunity to identify risks before they become diagnoses. Yet many practices either skip it entirely, confuse it with a routine physical, or fail to capture all billable components. According to CMS Medicare Fee-for-Service data, the AWV overpayment rate reached 24.5% with a projected overpayment of $307.5 million — driven almost entirely by incomplete documentation, not fraud. This checklist walks through everything a primary care provider needs to deliver and bill the AWV correctly in 2026.

Part 1: Is This Patient Eligible?

Before scheduling or documenting an AWV, confirm all criteria:

Patient has Medicare Part B

At least 365 days have passed since the patient’s Medicare Part B coverage effective date — patients within their first 365 days of Part B are not yet eligible for G0438; they qualify for IPPE (G0402) instead

No AWV or IPPE in the past 365 days — check claims history before scheduling to avoid a denial

New patient tip: If this patient is new to your practice, you may not have their prior Medicare history on file. Use your eligibility services provider or your Medicare Administrative Contractor (MAC) provider web portal to verify what benefits the patient has already received — including whether an IPPE or AWV has been previously billed. Portals such as CONNEX and similar tools provide detailed benefit and utilization history. For step-by-step eligibility verification guidance, see the official CMS FAQ: cms.gov/medicare/prevention/…/mps-quickreferencechart-1.html#FAQ

Timing rule — use month-based eligibility, not exact date: Medicare eligibility reopens on the first day of the same calendar month the following year. A patient who had an AWV on April 10, 2025, becomes eligible again on April 1, 2026 — not April 10. Scheduling on the exact anniversary date is not required and may cause unnecessary delays.

Clinical note: The AWV is not a physical exam. Do not conflate it with a problem-focused visit. It is a structured health risk assessment and prevention planning session.

Part 2: Which Code Do You Use?

Situation	Code	Frequency
Patient’s first-ever AWV	G0438	Once per lifetime
All subsequent AWVs	G0439	Once per 365 days
AWV delivered in an FQHC	G0468	Once per 365 days

Critical rules:

G0438 must always come before G0439 — if a patient has never had a G0438 anywhere, you must bill G0438 first, regardless of how many years they have been enrolled in Medicare. G0439 cannot be used without a prior G0438 on record.

G0438 is once per lifetime — a second G0438 claim for the same patient will be denied automatically.

Do not bill G0438 or G0439 within 365 days of billing G0402 (IPPE) — CMS will deny with a benefit maximum message. A patient can receive both G0402 and G0438 over their lifetime, but never within the same 365-day period.

FQHC providers bill G0468, which bundles the AWV with the standard FQHC service package. Do not bill G0438 or G0439 in addition to G0468.

Part 3: What Must Be Documented?

Required elements differ between G0438 and G0439.

For G0438 (Initial AWV) — establish from scratch:

Standardized Health Risk Assessment (HRA) — demographic data, self-assessment of health status, psychosocial and behavioral risks, activities of daily living

Height, weight, BMI, blood pressure

Review of medical and family history

List of current providers and suppliers involved in the patient’s care

Cognitive impairment assessment — use a structured tool (e.g., Mini-Cog); vague language such as “patient appears oriented” is not sufficient for documentation

Depression screening — validated tool (e.g., PHQ-2 or PHQ-9) with documented results

Review of functional status, fall risk, hearing, vision, safety at home

Written Personalized Prevention Plan (PPS) — required deliverable, not optional; must be individualized, not a generic printout; its absence can invalidate the entire claim on audit

For G0439 (Subsequent AWV) — visit requirements:

Update HRA and medical/family history

Weight and blood pressure — required by CMS

Height and BMI — not explicitly required by CMS for G0439, but recommended as best practice

Update cognitive and depression screening

Update and review existing Personalized Prevention Plan

Part 4: Optional Add-On Services — Don’t Leave Revenue on the Table

G0136 — Physical Activity and Nutrition Assessment

Administer a standardized, evidence-based assessment of physical activity and nutrition (5–15 minutes)

Bill no more than once every 6 months

When billed on the same AWV claim — no copayment or deductible; append modifier 33

When billed alongside a separate E/M or behavioral health service on the same date — copayment and deductible apply

2026 update: CMS revised the G0136 descriptor effective January 1, 2026. The code now specifically covers assessment of physical activity and nutrition only — it is no longer a general SDOH risk assessment. Documentation must reflect this narrowed scope.

99497 / 99498 — Advance Care Planning (ACP)

99497: first 30 minutes, face-to-face with patient and/or family/surrogate

99498: each additional 30 minutes (add-on to 99497 only)

When delivered same-day by the same AWV provider — no copayment or deductible; append modifier 33 on the AWV claim

ACP may also be delivered on a separate date outside the AWV — deductible and coinsurance apply in that case

There is no annual limit on ACP sessions per patient

Each ACP session outside the AWV requires documentation of a health change or updated patient wishes regarding end-of-life care

Part 5: Billing Summary

Code	What It Covers	Patient Cost	Key Rule
G0438	First AWV	$0	Once per lifetime; must precede G0439
G0439	Subsequent AWV	$0	Once per 365 days; requires prior G0438
G0468	AWV in FQHC	$0	Bundles standard FQHC services
G0136	Physical activity & nutrition assessment	$0 with AWV + modifier 33	Max every 6 months; 2026 descriptor updated
99497	ACP first 30 min	$0 with AWV + modifier 33	Same day, same provider
99498	ACP additional 30 min	$0 with AWV + modifier 33	Add-on to 99497 only

Part 6: Common Billing Mistakes to Avoid

Billing G0439 before G0438 — if no G0438 exists in the patient’s Medicare history, G0439 will deny

Billing G0438 more than once — automatic denial; always verify lifetime history before billing, especially for new patients

Billing G0438 or G0439 within 365 days of G0402 — CMS denies with benefit maximum message

Missing modifier 33 on G0136, 99497, and 99498 when billed same-day with the AWV — without it, cost-sharing may incorrectly apply to the patient

Documenting the AWV as a “physical exam” — creates audit risk and potential denial

Missing or generic Prevention Plan — must be individualized and patient-specific; a printed checklist without individualized content does not satisfy the requirement

Billing a same-day E/M without modifier 25 — if a medical issue is addressed at the same visit, it must be documented as a separately identifiable service with its own distinct note. Documentation for the sick visit and the AWV must be separate — elements and components documented for one visit cannot be counted toward the other. Append modifier 25 to the E/M code.

Part 7: AWV as a Gateway

The AWV is also a qualifying initiating visit for Community Health Integration (CHI) services when the provider identifies unmet social needs preventing the patient from completing their prevention plan. It is also the optimal touchpoint for enrolling eligible patients into Chronic Care Management (CCM), Remote Patient Monitoring (RPM), and Behavioral Health Integration (BHI) programs — all of which generate recurring monthly reimbursement separate from the AWV itself.

References

Centers for Medicare & Medicaid Services. Annual Wellness Visit. CMS.gov. Updated 2026. Available at: cms.gov/medicare/coverage/preventive-services/medicare-wellness-visits

CMS Medicare Preventive Services Quick Reference & FAQs. Available at: cms.gov/medicare/prevention/…/mps-quickreferencechart-1.html#FAQ

CMS. Checking Medicare Eligibility. MLN8816413. CMS.gov.

CMS. Medicare Claims Processing Manual, Chapter 9, Section 60.2. CMS.gov.

CMS-1832-F. Medicare Physician Fee Schedule Final Rule CY2026. Published October 31, 2025.

CMS. 2024 Medicare Fee-for-Service Supplemental Improper Payment Data. CMS.gov.

American Academy of Family Physicians. Annual Wellness Visit Coding Guide. AAFP.org. 2025.

***This article is intended for educational purposes only. Coding and coverage policies are subject to change. Providers should verify current requirements with CMS or their local Medicare Administrative Contractor (MAC).