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Medicare G0438 – G0439: Two Annual Wellness Visit Codes

Health Insurance Companies Process 1 in 5 Claims Wrong

Medicare Benefit: Annual Wellness Visits Covered

Back on January 1, 2011, Medicare started to provide coverage for Annual Wellness Visits. This benefit was included in the Affordable Care Act of 2010. Medicare has two HCPCS codes for these wellness visits for medical billing purposes. The codes are G0438 and G0439.

G0438 Annual Wellness Visit, Initial (AWV)

Annual wellness Visit, including a personalized prevention plan of service (PPPS), first visit.

G0439 Annual Wellness Visit, Subsequent (AWV)

Annual Wellness visit, including a personalized prevention plan of service (PPPS), subsequent visit. Annual Wellness Visits can be for either new or established patients as the code does not differentiate. The initial AWV, G0438, is performed on patients that have been enrolled with Medicare for more than one year. A patient is eligible for his subsequent AWV, G0439, one year after his initial visit. Remember that during the first year a patient has enrolled with Medicare, he is eligible for the Welcome to Medicare visit or Initial Preventative Physical Exam (IPPE). This exam is billed using HCPCS code G0402. An Annual Wellness Visit code of G0438 should not be used — and will be denied — because the patient is eligible for the Welcome to Medicare visit during the first year of enrollment. For more information on the Welcome to Medicare visit go to CMS.

What is included in an Initial AWV with PPPS?

  • Medical and family history
  • List of current medical providers
  • Height, weight, BMI, BP and other appropriate routine measurements
  • Detection of cognitive impairment
  • Review risk factors – Review of functional ability
  • Establish a written screening schedule for next 5-10 years
  • Establish list of risk factors
  • Provide advice and referrals to health education and preventative counseling services
  • Other elements as determined by the Secretary of Health and Human Services

The above list is just a summary. Check out MLN Matters Number MM7079 for additional information and links to other Medicare resources on services that must be provided at the AWV and subsequent AWV. Preventative Medicine codes 99387 and 99397, better known to offices as Complete Physical Exams or Well Checks for 65 and older, still remain a non-covered, routine service from Medicare. The Well Woman Exam codes G0101 and Q0091 are covered services.

For additional information, specifics, and more details, visit the CMS or your local Medicare carrier’s website. You can also contact them directly.

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is a 20 year veteran of healthcare having managed medical practices. He advises medical practices, physicians and practice administrators on how to run their practice and manage their medical billing and revenue cycle management. Manny speaks, blogs and makes videos at www.CaptureBilling.com, a blog that is tops in the medical billing and coding field. READ MORE

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454 Responses to Medicare G0438 – G0439: Two Annual Wellness Visit Codes

  1. I have a situation where pt has BCBS and we billed the preventive 99397, pt also has Medicare as secondary but his preventive is not eligible for the DOS what are my options in such case? Can I rebill secondary Medicare as a regular follow up(99213) or should I bill this to pt pr write off the charges?

    • Medicare will not pay for 99397. No, you cannot bill Medicare a 99213 if you performed a 99397 as that would be fraudulent. If BCBS did not pay I would bill the patient for the 99397 unless there is some reason you cannot.

  2. Hi Manny,

    Is this correct for Medicare Part B/ Blue Advantage?

    G0489 25 z00.00
    99497 33 Z71.89
    90674 Z23 flucelvax quad single pre-filled syringes
    G0008 Z23 Admin

    Is the Admin code 90471 usually used for BCBS commercial? Thank you for the information!

  3. Please help. My provider was told at a meeting recently that all GCODES can be done by a RN or certified Medical Assistant. He is under the impression IPPE and AWV can be done by them in office as long as he is here in the suite. Please advise.

    • My limited understanding is that they can do part of it, but the NP or MD must be the one to make the plan and recommendations in order to bill medicare.

    • Hi Nicole —

      The following info is from CMS:

      Who can perform an Annual Wellness Visit?
      Medicare Part B covers the Annual Wellness Visit (AWV) if it is furnished by a:
      • Physician (doctor of medicine or osteopathic medicine)
      • Physician assistant
      • Nurse practitioner
      • Clinical nurse specialist
      • Medical professional (including a health educator, a registered dietitian, nutrition professional,
      or other licensed practitioner) or a team of such medical professionals working under the direct
      supervision of a physician (doctor of medicine or osteopathy)

      Who can perform an Initial Preventive Physical Exam?
      Medicare Part B covers an Initial Preventive Physical Exam if it is furnished by a:
      • Physician (doctor of medicine or osteopathic medicine), or
      • Other qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical
      nurse specialist)

      For the AWV after the RN completes the questionnaire the Physician should then review the questionnaire with the patient and come up with the personalized prevention plan of service for the patient.

      Check with your local Medicare carrier for specific information.

      SOURCE: https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/IPPE-AWV-FAQs.pdf

      Hope this helps.

  4. Please help me with this debate. A group of providers is telling my provider that all Gcodes can be done by a Certified Medical Assistant or RN. Provider is being told AWV,IPPE can be done by them as long as he is in the suite. Please advise 🙂

  5. Does anyone know if you can bill for Advance Care Planning 99497 as a “stand alone” visit with out an office visit charge, or any other charge, or any modifier, and be paid for it? I had a patient come in with an Advance Care Plan he created at home and he wanted me to see it. I looked at it and made some changes to it with him, but nothing else was done. Thank you!

  6. Good morning!
    I am going a little crazy trying to get these paid. Any help would be appreciated. A E/M was billed with wellness visit and patient recieved a steriod injection. Everytime we bill a 96372 they will pay it and deny the 99497 for global. We use the 33 on the 99497 should we do a 25 on the 99497?

    G0439 Z00.00
    99497-33 Z00.00
    99214-25 R09.81,L98.9,I10,E78.2,148.00,M19.90,J449,E03.9,Z98.0
    96372 R09.81
    J1100 R09.81

      • Tawanna, Do you mean to not list R09.81 with the other chronic conditions on the 99214 and only list it with the 96372 and J1100? thanks

          • Manny,

            I have a queston about flu vaccines. We are giving some with our AWV’s. Here are my questions:

            How do I bill Medicare Part B (office) for flucelvax quadrivalent, 0.5 ml prefilled syringes, NDC 70461-201-01? with 90674 and G0008 (admin)?

            Will these CPT codes change in 2018?

            Are the codes different for Blue Cross Blue Shield (of AL) commercial?

            Thank you so much for you help!

          • I am having an issue with being reimbursed from Medicaid for the 99497. Does anyone know why Medicaid will not pay either as Primary or Secondary? Our denials are coming back stating POS and procedure code are invalid, when we speak directly to a Medicaid rep they want a manual fee and additional supporting documentation on a new claim. Please help

  7. If our provider sees a patient in a nursing home with a 99308, can we also bill a G0439 or G0438 on the same day? Would we use a modifier?

  8. Our office is doing AWV and we can’t seem to get the depression screening paid for
    I have paper work that tell me G0444 is not pd with G0402 or G0438 but is pd with Go439 if I put the modifier 33 on the G0444. However that was not pd. When I called medicare they of course would not share what modifier to use. I have had them tell me to use 59 on the G0444 and have also had them tell me to use nothing.
    I am hoping you will be able to shed some light of this issue for our office.
    Thank You

  9. Hello ,

    It’s my understanding that we perform an AWV during a “follow up visit” where a patient is doing fine but here to discuss their chronic conditions and refill their medicines. For example:

    G0438 Z00.00
    99213 -25 I25.10 K21

    As long as the documentation supports the follow up visit as well as the AWV (even though they overlap a bit). Is that correct?

    • What I meant to say on that last question/post was that- “can we perform the AWV with a follow up visit (per patient request) with proper documentation supporting both visits (even though they overlap a bit)?” I undersatnd that the patient is responsible for the 99213 portion of the visit. thank you

  10. Hi Manny,

    I have 2 questions please: We recently began performing the AWVs in our office. When we submitted our 1st couple of claims, we didnt’ realize that out practice management made 2 separate claims for the CPT codes -instead of one:

    G0438 Z00.00
    99213 -25 K21, I10
    Although Medicare paid them correctly, do we need to fax/mail a Part B Overpayment Refund / Notification form to refund the payments and “clean the slate” then resubmit a single claim with both CPT codes? Or should we leave it alone?

    Question 2: I recently submitted this claim to BCBS and it paid without problem:

    G0438 Z00.00
    99406 -33 F17.210 Z71.6

    I sent the same claim (on another patient)to MCR and the 99406 was rejected with an “invalid modifier” After much research, is the correct modifier CG?

    G0438 Z00.00
    99406 CG f17.201 Z71.6

    If so, do I now resubmit the claim with the corrected 99406 modifier even though I know the G0438 is in process and will be paid correctly?

    Thank you so much for your help!


  11. We recently met with our Humana Medicare Rep. who let us know that new as of 2017 Humana Medicare is now covering a Annual Physical exam separate of the annual wellness. I believe she said there is a however a $15 copay for the patient. I have since emailed her to confirm that information. Does anyone else know copay amount?

  12. Hi Manny,

    Can you tell me:
    1. Can bill for ACP discussion that does not take place with an AWV?
    2. Or is it only billable when you provide an AWV at the same time?
    3. Is there more than one code for billing ACP, I know of 99497 only.
    Thank you, Maureen

    • You can bill for ACP alone in 30 minute increments. 99497 is first 30 minutes, there is another code for additional 30 but that would be a rarity. Do not add a modifier unless it is provided during the AWV.

      If provided during the initial G0438 keep in mind that MCR may consider the ACP bundled and will likely not pay separately. If provided during subsequent G0439 it will be paid separately with appropriate modifier.

      • Hi Chris. I had a patient come in just to bring in an advance care directive he created at home and wanted me to look at it and discuss it. There was no other reason for him to be in the office (no illness, exam or AWV). I want to bill for the time spent on ACP just as a stand alone visit. Do you know if this is possible?

  13. I’m sorry to add onto the forum here but I need to ask, when billing injections do we need to have vitals ? I understand not having vitals for labs but for nurse visit doing injections is it required and a chief complaint require for injection too?

  14. hi Manny,

    Can I bill this and get paid:

    DX is : patient’s BMI & z000
    99211 mod 25
    86850- TB test
    Can you bill G0438 by itself without the modifier and the Z000 DX code?
    Thank you

  15. Hi Manny,

    A patient came in for an annual wellness visit and a Mantoux test, can this be billed as follows in one visit:?

    DX: Z00.00, Z68.36 (BMI)
    99213 with Modifier 25

    Also can the G0438 or G0439 codes be billed by themselves with the Z00.00 diagnosis codes? Our software does not seem to allow the physician to put in the G codes on his end, without an E/M code. Thank you.

  16. Hi Manny,

    I am a new MCR provider and I saw a MCR pt for a general wellness check up who says he has not been seen by a PCP in several years.Will he be eligible for the initial annual wellness visit G0438? How do I find out whether or not he has been billed for this before?

    • Well, you should be able to log on to your local Medicare Carrier’s website and check for AWV eligibility. It has been several years since the patient saw their PCP last and they may not know how the practice coded for their services. Make sure you obtain a signed ABN just in case. That way you can bill the patient if needed.

  17. Could another practice haves billed for this? Go to your MAC portal under preventive under eligibility and look for the G0439 code. It will tell you when the patient’s next eligible date is. Could the diagnosis be invalid?

  18. Why is Medicare denying G0439 when it has been over 1yr since last phy? We are charging the G0439 and 99214 plus 25 modifer if needed on 99214. Thanks!

  19. The Medicare portal for your Medicare carrier should have preventive tab under eligibility for your patient(s). This will tell you the next eligible date for G0439. If you have a “stand-alone” practice, you can bill new patient visit with 25 modifier. If your office/HCP is part of a group of doctors billing under the same PTAN/taxonomy, and the patient has had face to face with any of those doctors within 3 years, then you cannot bill new patient visit.

  20. Hi Mr. Olivarez I currently am subscribed to receive your emails and find the information to always be so helpful, thank you so much for all you do! I have a question, if we bill Medicare G0438 and it denied as paid only once in a lifetime; we later find that the pt had this done by another physician can we change the code to G0439 and refile? and also the patient is new to our practice has never been seen if we are allowed to change from G0438 to G0439 can we do so even if the patient is new? I understand that in order to bill G0439 must be within one year of the G0438 but what if it has not been the year, then what do we do? Are we allowed to bill new patient visit 99204?

    • If I mistakenly billed G0438 I would submit a corrected claim with G0439. It is not relevant, when billing and AWV, that a patient is new or existing. Also, there must be a year between AWVs. I like to say a year and a day to make sure. If it has been less than a year since the last AWV and the doctors perform another AWV, Medicare will consider it not medically necessary. You are free to bill for any problems a new patient comes in for using a new patient EM code.

  21. Our physicians would like to begin reading and interpreting overnight oximetry and PFT/spirometry results for our local hospital. Our physicians would be ordering the test and the local hospital performing the test. Is there a separate, billable profession component for these tests?

    • Sounds like you would bill using the CPT code for the test and appending a 26 modifier to indicate that you are only billing for the professional component of the code. The hospital should bill the code with a TC since they are doing the technical component of the test.

  22. Medicare will allow an Annual Wellness Visit G0439 twelve months from their last. It can be done on the first day of the month since this last. For example, patient had AWV on 09/15/2016 so he is eligible on 09/01/2017.
    UHC requires 366 days, so if patient has AWV on 09/15/2016 he is eligible again on 09/16/2017.
    Do you know the requirements for other health care plans such as Humana, Aetna and any other medicare insurance plans?


    • Hi Sandy, Sorry I missed your question. I would contact your provider rep for each insurance carrier or go to the plan’s website. As a policy, we tell our providers 1 year and a day for the next AWV and always have the patient sign an ABN.

  23. Hi Manny,

    We have a patient coming in for their AWV G0438 plus a 99497 ACP. Are these the correct diagnosis codes and modifiers?

    G0438 -25 Z00.00 plus any other chronic conditions
    99497 -33 Z00.00 plus any other chronic conditions

    I’m pretty sure that the 99497 requires the -33 modifier but I wasn’t sure about the G0438 with modifier -25

    Thanks so much for the help!

    • You can use modifier 33, preventative service, to tell Medicare that there should be no co-insurance or deductible when 99497 is done on the same day as an Annual Wellness Visit. No need to use modifier 25. ICD-10 codes Z00.00 or X00.01 are fine to use. Check with your local MAC.

  24. what is the difference between G0402 and G0438? We billed Medicare G0402 within the first year of the patient’s eligibility and was paid. After one year, can we bill G04038 or should we bill G0439? I know we can bill G0438 if the patient missed the G0402 within the first year of eligibility.

    • G0402 is the “Welcome to Medicare Exam” which is basically a routine physical which can only be done in the first 12 months the patient becomes eligible for Medicare. G0438 is the code for the first, initial, Annual Wellness Visit. All subsequent AWVs are billed using G0439. At the AWV the provider discusses a plan of preventive care for the patient for the coming year. There is no physical exam.

      To answer your question G0438 would be billed since it is their initial AWV.

      • Am I correct in assuming
        G0402 is billed if their 1st Wellness visit is within 12 months of Medicare enrollment

        G0438 is billed if their 1st Wellness visit is past 12 months of Medicare enrollment

  25. Can you bill the G0438 in a dialysis setting? The dialysis unit is a clinic owned unit. The provider is seeing the patient doing the wellness visit and then the patient is receiving dialysis. We are billing with POS 65.

    • Loretta I haven’t come across that one before. I would check with your local Medicare carrier to be sure. If you have already done the service, bill it and see what they say.


  26. I have an URGENT QUESTION Regarding billing for “PREVENTATIVE CARE” We have been billing a few cpt codes: These tests are showing medical necessity, but are considered to be PREVENTATIVE IN NATURE: as all of the testing that we are doing is to PREVENT ADDITIONAL ISSUES with the patients: Such as Neuropathies for our Diabetic Patients, Cardiac Issues with our patients with Cardiovascular issues

    Can I bill 93923, 95923, 95924,

  27. I also wonder why on the Medicare eligibility website it has a modifier 26 next to the G0438 and G0439 …it is a Professional component…when would that be used?

    • Lisa I can tell you I would never use a 26 modifier on an AWV code. Can you please share the link to the page you found the info on? Post it as a reply to these comments. I would like to check it out.

      • It actually was when I went thru connex to look up pts eligibility ….it used to be called entitlements now eligibility …lists what they are eligible for then next to it there is a column with modifiers,eligible date ect …both of the codes have the mod 26 next to it

  28. Hello Manny,
    I’ve been reading and studying these post for a couple if days. You are a wealth of knowledge. I am new at coding and have several questions: (I’ll start with a couple as not to overwhelm)

    1. I understand the difference between the IPPE G0402, 1st AWV(G0438) and subsequent AWV (G0439. I was wondering which Dx codes should be used with the visit…Z00.00/ plus any Chronic Condition codes? I understand that Z00.01 can only be used if an abnormal finding was found on that day.

    2.I have CAHABA GBA InSite web portal which allows me to check patient eligibility (entitlements) for preventative services. On the page I can see, it shows the date the patient is eligible for certain services. If it says the patient is eligible for the IPPE on the same day they became a Medicare beneficiary (for example in 2012), then I assume the patient never received this G0402 IPPE visit and can longer receive it since it has to be done within the first 12 months on Medicare. I also see that her G0438 & G0439 has an eligibility date of 1/1/2013. It also has a Modifier column on the screen which states 26. What does this 26 mean? (I know that it means Military treatment facility in the CPT book but she isn’t Military) And do we perform the G0438 with the Dx code Z00.00 plus any chronic conditions?
    Thank you for you help. I’ve researched for days trying to find a place to ask questions.


  29. Can we bill an annual wellness exam and an E & M code (ex 99214) for the same patient, on the same day, in the same office setting, but with different providers within the office? One provider saw the patient for the wellness exam and another saw them for a checkup.

    • Yes you can bill for both an AWV and an E&M code. In your scenario you indicated that another doctor saw the patient for a checkup. By checkup if you mean a routine physical exam its not covered by Medicare and you would bill the patient. If female and a pap and breast & pelvic exam were done then you would carve those services out of the checkup and bill that portion to Medicare.

  30. I have providers wanting to report an AWV along with a problem oriented visit and a physical examination on the same date for those that carry insurance that will cover the physical Exam. I have not seen this done and my concern is that too many components of the PE and the AWV would overlap to support reporting both services. Does anyone have any reference sources that would support reporting or not reporting all three together. Again, concern is with the CPE and the AWV – same date.

    • Hi Eileen,

      I am a consultant and I help practices launch internal AWV programs. Any time that my client wants to do this I always advise them that proper compliance would be for the PE to be completed and billed on a separate visit (preferably on a visit AFTER the AWV has been done). Every year the AWV can be used for screening purposes (along with a regular problem oriented visit), and then the PE can occur on the patients next visit. Rationale being that the AWV should have established a ‘goal’ for what conditions or risk factors would be addressed for the next 12 months as the PE has patient edu components. See how it all comes together?


      • Chris great advice. We do have a practice that has done the AWV, a PE and a problem-oriented visit all on the same day. The documentation is separate for all visits. The provider uses the AWV as a’goal’ like you indicated and then goes on to perform the PE and at times, if warranted, a problem visit.

        You did mention proper compliance is that the PE is to be performed on a separate visit. Do you have a link with documentation from CMS on this that you could pass along?

  31. Can anyone please tell me exactly what documentation is required for a medicare wellness visit? I am new to this and I am getting differing answers from my management.

  32. Hello,
    I am wondering if anyone knows where you can find examples of when an E/M code can be billed in conjunction with an AWV (G0438 or G0439). I want to make sure that we are billing E/M services when appropriate. Also, any information in regards to what documentation is required above any beyond the AWV note would be helpful.
    Thank you

    • Leah,

      An E/M code can be billed in conjunction with an AWV anytime that a patient presents with a symptom that requires diagnostic evaluation by the physician, is medically necessary, and is separately identifiable.

      As an example, say a patient is being seen for an AWV and they have a severe cough that they also want addressed. The doctor can address this separately at the time of the visit and both services can be paid (for example G0438/9 with Z00.01 and 99214 with J44.9). This example uses unspecified COPD as an example of the ‘sick visit’ reason.

      With regard to documentation what do you mean by AWV ‘note’? There is actually quite a bit of documentation required for Annual Wellness Visits. Can you be more specific?

      Hope this helped

  33. Do Medicare Annual wellness visits have to be done in clinic. Can they be done over the phone or at home such as home visit?

  34. We are getting refund requests from UHC Medicare Solutions for G0439 visits. We filed with ICD10 Z00.00 as always – they paid the claims and now they are telling we used the incorrect ICD-10 code, although they can’t tell us what code they will accept. Suggestions from anyone??

    • the only other code you can use is Z00.01 which is abnormal physical- and we determine that in our office if the patient requires follow up visits after that physical then they are abnormal.. I rarely use normal except for younger adults

  35. Thoughtful piece – I learned a lot from the facts. Does someone know where I would be able to obtain a fillable PDF Calendar example to work with ?

  36. Do you have to use a modifier for G0438 if you are providing this in conjunction with 99497? Do you need a modifier for the 99497?

  37. Hi Manny,

    I we are doing the AWV at our practice and we are billing as follows CPT/Mod/Dx:


    Now I know that G0444 doesn’t get paid with G0438 which is fine but what is interesting is that Medicare will pay for G0438, 99497, and E/M for a few…..but most come back just paying G0438 and 99497.

    Why would this be? Reason we are given is a ’49’ saying E/M isn’t paid because it is a preventative service??? ????

    • You can not use Z0000 with Medicare and Medicare plans as they do not pay for preventative services, you can only use diagnosis codes. Make sure Z0000 is not listed anywhere on the insurance claim form or it will get denied.

    • Hi Manny you can disregard my last comment and question turns out the docs we’re also using Z00.01 on the E/M which of course would cause it not to be paid as that is not a problem related diagnoses.

  38. The TB test was 86580 with the admin code 96372 we also billed G0439 . I will remove the 25 modifier and see if the G0439 will get paid.

  39. I billed a G0439 with a 25 modifier on the G0439 also on the same day we billed 86580 TB and 96372. I was denied by medicare for the following reason . The procedure code is inconsistent with the modifier used or a required modifier is missing. Should I not be billing for the 96372 administration fee . or am I using the wrong modifier . There are asking me to resubmit a new claim with the requested information. Any info would be greatly appreciated.


    • I don’t think you need a modifier code for straight Medicare if it is during the G0439 visit. If it is a level 3 then you do use the modifier code

      • Becci we have been using the modifier for years… if they are Medicare or replacement plans doesn’t matter. if you read my initial comment below it has been happening this past few months, and I wasn’t the only person who responded. So this is a new issue.

    • My suggestion is bill G0439 w/ your z00.00 & 86580 z11.1 only, B/c Reporting 96372 for placement of the PPD is inappropriate the administration is inclusive. I would also bill for the reading of the TB when coming back but only report 99211 if the nurse evaluates the tests results and documents.

  40. So since August we have always had no problem with G0439 with a 25 modifier if we are doing any vaccines in office or other procedures we can charge for…but our new EMR system this year keeps pooping this up now:
    Rule: Procedure Code/Modifier Mismatch [359]

    [Medicare] Modifier 25 is not listed as reportable with procedure G0439. Please review the procedure coding and modifier usage on the Claim Edit screen.
    To help you resolve this issue, more information on modifiers that are appropriate for procedure code G0439 can be found in athenaCodesource.

    I go to their code source and all I see now is a 99 modifier which I have never used…anyone else having issues or is it just Athena’s EMR

    • Marcie,

      Did you get any resolution to this? I’ve been having the same problem and contacted Athena and they said maybe medicare changed their rules. They have not.

      • No I have not- I have tested a few claims with sending w/o the modifier so I can keep tabs on and some with the 25- and having to force drop with a CCO – I agree you think we would have heard this at the beginning of the year not in the middle!

      • Kristen I went to look at the charges I have done with and without the modifiers and both types of claims have been paid. I just do the CCO override on Athena until they fix their mess…because it proves no point.

  41. Manny,

    I was recently advised to consider adding the AWV to our SNF providers list of things to do. I reviewed several of your past posts to see what you thought. I do not see answers to the SNF posts. So I will ask a different way.

    Does the place of service matter with the AWV or the IPPE? (I do see the post on home health, thank you. I am most interested in SNF if you have this information.)

  42. We have a patient that had her Welcome to Medicare (G0402) in July of last year. Of course she’s new to us and said she hadn’t had a physical or anything of the sort in the past few years. Because we had new front office staff, they did not call Medicare with the question prior to the patient visit. We billed the G0402 and was denied. We refiled with G0438 and have been denied again because we did the exam in April of this year and it’s been less than 12 months. Are we able to bill the G0439 or are we just going to have to bite the bullet for this one?

    • Jessica, first of all a G0402 is different than a G0438. Did the provider perform and document all the elements of a G0438 when the Welcome to Medicare exam was done?

      There is still a 12-month minimum time when performing any Annual Wellness Visit so a G0439 would not fly.

      Now with an AWV you do not need an ABN signed so you are able to bill the patient for the visit and get paid.

      So you can either bill the patient the full amount or start biting that bullet and write off the claim.

      • Thanks so much for the timely reply. I understand the differences between the codes. The provider had adjusted the note to reflect the different code being billed since the correspondence had originally come back within 14 days of the pt visit. Yes, the provider did document everything associated with the G0402 and G0438 because he wasn’t sure which one he was doing originally.

        I did not know that about the AWV and ABN… thank you

    • Kathleen that is not true. A GYN can do an Annual Wellness Visit. My guess is that they don’t want to becasue they are afraid that the primary doctor may have done the visit previously and the GYN will not get paid.

      This visit can only be done once every 12 months. We have had doctors perform the service only to find out later that the patient had a wellness visit from another doctor within the 12 month period resulting in the claim being denied and the doctor not getting paid. And yes, the patient had told the doctor that they had not had one in the past year.

      Now the doctor can have you sign what is called an ABN, Advanced beneficiary Notice. This notice that you would sign states that if Medicare does not pay you will be financially responsible. This way the doctor can bill you if the visit was done within the past year by another doc and Medicare doesn’t pay. Without the ABN signed the doctor cannot bill the patient.

      One other thing to note is that the Annual Wellness Visit is not a routine annual exam. That exam is never covered by Medicare.

      • You can go to your Medicare portal, go to Eligibility, complete the info. Then pick preventative. (At least in CGS). Sort by code, and it will tell you when patient is eligible for whichever preventative code, G0439, etc.

  43. I am having a HORRIBLE TIME billing for medicare GYN exams!!! I dread each call of a patient calling about the balance!!!! Then they call medicare and they just tell the pt we coded it incorrectly to get them off the phone. Then they call us for the 100th time and we explain the same thing and get yelled at.

    I wish medicare would actually explain that the well woman portion 99397 is NOT covered instead of just trying to get them off the phone!!!!

    • Are your providers billing for the G0101 and the Q0091? You are you carving those 2 codes out of the 99397 and billing the patient the balance? Are the providers and/or the front desk telling the patient that a provider will be doing a full physical and only the gynecological exam part of it exam may be covered by Medicare?

      Carolyn Dunn over at Rio Grande Hospital saw your post and emailed me and said:
      “My understanding is that the gyne exam code is G0101, not 99397 which Medicare will not pay for. Gyne exams can only be done every 2 years unless the patient is high risk.”

    • Carol also said:

      “Currently we would bill the G0438 or G0439 and if a gyne exam G0101 only if that hasn’t been done in the past 2 years. We currently do not bill for the Q0091, it’s not in our Charge Master. We have not been billing our Medicare patients the 99397, we only do the annual wellness exam. If we address anything else in addition it is usually and E/M code with modifier 25.”

  44. I am still not getting paid for what I believe KS Medicare says is allowed. I bill G0439(well exam), 99497-33 (rvw health care directive), G0444(screening depression), G0442 (screening for alcohol abuse)Medicare is only paying on G0439 and 99497-33. How do I get G0444 and G0442 paid?


      • You must use modifier XU on those. Be sure you do or Mcare will split the claim then they won’t pay since not included with the G0438/9. The depression screen is included in the wellness and/or G0402.

    • Hello Tarra,

      From my understanding, you should be getting reimbursement for your screenings (G0444, G0442) because you are billing it with G0439. Those screenings are not bundled into subsequent visits, so it is acceptable to use those G codes. My suggestion would be to use a -59 modifier and see if that works. Medicare tends to look for the -59 modifier and will send back claims without it.

      • We have been using the modifier 59 on G0444 when doing G0439 and we are not getting paid

  45. What if your patient never had an IPPE as they were already enrolled in MCR when the services started …how do they get their one time only screening EKG? how do we code for that?




  47. Can I bill a 99214 instead of the HCPCS code of G0438, G0439 before enrolling a patient into Critical Care Management? Or do they have to be combined?


  48. Can a PCP provide AWV at a patients home? I don’t see that specific POS on the MM7079. He is not home health- just a PCP that provided a home visit and completed the AWV at that time.

    • Yes in my experience, I have seen Annual Wellness Visits being done at Home, POS 12. THis is acceptable by insurance.

  49. Do you have to spend greater than 15 minutes with the patient to justify G0444, or can it be less than 15 minutes?


  51. I am billing G0439, G0444, 99497-33…Medicare is not paying for the G0444, I have tried modifier 25 and 59 on the G0439 but still not working. Medicare customer service is no help..Any ideas on how to get all 3 paid?

  52. We are seeing rejections from Medicare when billing G0438 Mod-25 Z000 with EM code (99213 + Problem DX).
    Medicare is rejecting with CO16 and M20 when we bill this.
    Anyone seen this as well?
    Should the EM / Problem have the Mod-25?
    What additional info is medicare wanting for these claims?

    • You should always have the 25 modifier on the E/M ….”25″ modifier is a E/M modifier and not preventative modifier…..file a corrected claim or call CER line and add the modifier 25 to your office visit and remove it from your AWV and your claim will pay.

  53. I am dealing with Caresource Just4Me witch is a Marketplace Exchange plan & they pay claims at medicare rates. When 90715 is billed with Revenue code 636 that line gets denied stating “Submitted revenue code has been billed without a needed HCPCs code or was submitted with an invalid HCPCs code per established guidelines” when reviewed by coding Im told the rev code & HCPCs codes are correct so whats the issue?

    • Sunny I agree that it is hard to tell as the patient sometimes does not know if they have had an AWV previously. We just make sure that the patient signs an ABN so that we can bill them if needed.

      • You can obtain the patients AWV eligible dates on Novatisphere. Google if you don’t have access. It is a it cumbersome to obtain access but well worth it once you do.


    I’ve heard letters of warning and PENELTIES are being sent out from medicare and large PENELTIES at that!

    Please advise

    • Amanda —

      We have not billed an AWV for anyone under the age of 65 but Medicare does not reference age, only enrollment with Medicare.

      per CMS:

      “Medicare covers an Annual Wellness Visit (AWV) providing Personalized Prevention Plan Services (PPPS) for beneficiaries who:

      — Are not within the first 12 months of their first Medicare Part B coverage period; and
      –Have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months.”

  55. Just following up…Does anyone know of a CMS site/reference that specifically states G0402/G0438/39 are reimbursable if the visit is done in the patient’s home. Before my employer will create this position for me-they want documentation from a CMS site that it is indeed reimbursable. I have read hours of CMS/Wellness info and cannot locate this specific information.

  56. Naveen – do you know if a CMS website I could reference regarding Medicare wellness visits allowable in home? My organization would like this before proceeding further and performing any visits in home.

    • Thanks so much. Is there anywhere I can reference on the CMS website regarding locations they can be done? I am an NP and have submitted a proposal as a new position to do some of these in the homes. Before this is implemented my organization will want to be certain they are reimbursable. I spent hours on different CMS websites yesterday and found NOWHERE that it stated they can’t be done in home but will need a reference point to show that they are allowable in the home. Can you point me in right direction as to where I might find this info? Also… Thanks so much for your prompt response earlier.




  58. Hi Manny,
    Why does Aetna reject this: on same DOS, 99212 + M17.0, G0439 + Z00.00? Says” invalid information: ICD10; at least one other status code is required to identify the related procedure or diagnosis code”? Non-Medicare patient.



  59. Hello Manny,

    Recently our Connect Care system personnel at our very large Bonsecour Health system has changed the due date for any subsequent Wellness visit (i.e. G0438 after a G0402 or G0439 after a G0438)in Health Maintanence(which shows in a patients chart when preventative services are due) to 335 days (11 months) and sent out a notice that they can be done as long as 11 months has passed. However, when I check the Medicare A/B standard policies for eligibility dates they are giving a 12 month waiting period. I have also been told that Contract Medicare policies such as Humana, UHC, Cigna can be done any time with the new contract year (Jan 1-Dec.31)even if the patient was just done the end of 2015. I am not getting any response from management or connect care so I thought I would write to you if you can help clarify these issues for us. Thank you! Karen, Medicare Wellness RN.

  60. Hello,
    Recently our office changed billing services. Prior to this change the providers where billing a 99397 along with AWE since they are two separate exams and for the most part getting reimbursed. The new billing service is telling us we cannot do this. Please advise if these two codes can be billed during the same visit and what insurance companies will reimburse for both (I understand straight Medicare will not).
    Thank you,

    • Hi Kristi —

      You sure can bill for both a 99397 and the AWV. Of course the 99397 would be the patient’s responsibility, as you understand already, but Medicare will pay for the G0439. We have seen a few secondary insurances pay for the 99397 but not many. We don’t keep a list of those as it can change at any time. You can even bill for a problem oriented E/M code such as 99212 if appropriate. –Manny

  61. Hello!
    I have AWV claims denied due to “Invalid place of service” on Nursing Home patients. I am a rounding physician. Please let me know if you know anything about that issue.
    Thank you!

  62. Hi there,
    @Manny Oliverez
    I have been reading and getting help always by reading your posts. I have few questions if you can please help me. I will really appreciate it.

    Question # 1 = If patient is coming in for an office visit for annual wellness visit follow up, what diagnosis code should be billed if doctor has not found any issue in patients lab results or general checkup ? Z00.00 is already been billed for the first visit and paid but I know for sure if I will bill Z00.00 with 99214 insurance will Denny the claim. Please Advise. Thanks

    Kind Regards,
    Muhammad Imran.

    • Imran when you bill the office visit, you need to look for the other complaints the patient may be having and that diagnosis code should be used as the Primary diagnosis code. This is in case the office visit and the wellness visit are done on the same day.

      • But sir I have couple of patients who dont have no issues at all but they came for office wellness visit and they were recalled by the Doctors for a lab follow up. I have already billed their wellness visit with Z00.00 Dx code and the claim is paid but their follow up visit is still left and I dont have any Dx code to bill.

        • Another question if you can please help me on this as well. How can we get paid by Government plans such as Medicare, replacement plans, Hummana Medicaid for 90636 (HepA-HepB) Vaccine & 90715? I have used Z23 (ICD 10) and Admin code as 90471 but they dont pay for it at all yet.

    • Imran, if you don’t have another reason like a medical complaint/illness from the patient, you cannot do a followup visit. I would suggest you write it off.

      • Thanks. and what about my other question.

        Another question if you can please help me on this as well. How can we get paid by Government plans such as Medicare, replacement plans, Hummana Medicaid for 90636 (HepA-HepB) Vaccine & 90715? I have used Z23 (ICD 10) and Admin code as 90471 but they dont pay for it at all yet.

  63. Hello, I am having NO luck billing for wellness visits to Medicare. I just billed a G0438 for a patient who has been with our practice for 3 years but we have never billed a wellness visit. It was denied by Medicare because “lifetime maximum benefits has been met, service already paid once in a member’s lifetime”. WHAT??? so this code is a ONE TIME THING?? Why does Medicare not make that clear and what code do I use instead? Thank you, Kathie


      • You can always check the Medicare website in the eligibility section. Once in the patients eligibility section there are 9 tabs near the top. The tab on the far right is Preventive. Here you will find a list of when the patient is eligible for different preventive blood work and exams. It is very helpful. If the patient was not eligible at the tos and there is an abn on file, you can bill the patient.

  64. On the day you arrive at the doctor’s office, Does the biller know it’s your annual wellness visit and there is no copayment?

    • Catherine it has to do with the service the doctor provided, not the biller. The biller can ONLY bill what the exam documentation indicates the services where that the doctor performed.

      Now if the doctor indicated on the checkout form when you were done with your visit that an Annual Wellness Visit was performed then the Cashier that collects your co-insurance should know that there should be nothing to collect. When a patient has Medicare and a secondary insurance it is difficult to know what exactly the patient will ultimately be responsible.

      Most doctor offices will wait to hear back from all insurance companies to see if they made the patient responsible for and amounts and then send the patient a statement as appropriate.

      Does this help?

  65. Can my family practitioner perform the G0438-G0439 to our long-term nursing home patients at the nursing home facility?


    • Yes, I am told that you can bill a wellness visit with an E/M code such as 99213. Just add modifier 25 to the E/M code and make sure that the pt was in for more than just the wellness visit and it is properly documented.

  67. Hi, I have a question. I have a patient with “X” complaint today. But he qualified for (G0439) with 99213 there is correct?

  68. Hello I have another question , I have two claims denied with 90715 tdap vaccine . Being denied because insurance said it can’t pay for code because it was done in office . Is there a different code I have to bill for the vaccine given in the office ? Please help !!

    • In reading the article, Medicare GO438-GO439: Two Annual Wellness Visit Codes, I have a question regarding the HCPCS billing code GO402 which the article says to use for billing an initial wellness visit the first 12 months of Medicare coverage. I understand that to mean GO438 is not a billing code. Therefore, does that mean that there are two codes for each; one billing (GO402) and one for the exam done (GO438)? Could this GO402 on line 13, subtitle: GO4039 Annual………..Subsequent….. Could this be a typo error and should be GO438 (initial exam)?
      I am trying to learn the proper billing codes and thought that the two numbers GO438,GO439 were the billing codes. Thank you for clearing up my confusion.

  69. Hi manny , Humana is denied three of my claims stating g0438 isn’t a billable code only billed with Medicare , do you know what code I can bill to get my claims paid ?


  70. will I get pay for seeing patient for 2 reasons, G0439 and routine check up 99349 on the same date of service?

    • Yes, you will get paid as long as you have this specific reason for doing the 99349. Make sure you use the appropriate modifiers, like 25.


    • First find out the eligibility for the patient with Medicare; whether this is a Welcome to Medicare Wellness Visit (G0402), Initial Wellness Visit (G0438 – billed subsequent year after billing the welcome visit), or a subsequent Annual wellness Visit. If the patient is eligible, try billing the claim back with ICD code V70.0 along with the appropriate code as given above.

  72. Manny,
    United Healthcare Medicare Advantage program (AARP) is paying for a yearly physical (99397) as well as the IPPE or PPPS codes. We have been told that United will pay for the G0438 and G0439 “once per calender year” and that they don’ require 12 months to have pased. I am concerned that we are being misinformed By United and these will ultimately be denied.
    Can a Medicare Advantge provider change the policy of providing this preventive service less than 11 calender months from the previous visit?
    I understand they can add services such as paying for 99397 but I didn’t think they could or would change the benefit rules for the G0438 or G0439.

  73. I would like to know the exact cpt code for Welcome to Medicare exam. Is it G0438. This would be for a patient that just turned 65 and this is her welcome medicare exam. Medicare is suppose to pay for the welcome to medicare exam but it keeps getting denied by medicare.

    • THE WELCOME TO MEDICARE ANNUAL WELLNESS VISIT SERVICE IS BILLED USING THE CPT CODE G0402. This should get paid because this is the first wellness visit after the patient got her Medicare.


  75. Hi,
    What if my practice bills G0439 when the patient is due for G0438. If a year has passed since then, am I able to bill at his next visit the G0438 and get it paid by Medicare?

    I have been looking everywhere for that questions and I can’t find an answer.


  76. Hi Manny: Our Family Medicine Practice is located in Virginia. We currently use LPN’s under the direct (on site) supervision of a physician to do our G0438 and G0439 HCPCS Medicare Wellness Visits. We are considering hiring a Certified Medical Assistant. In Virginia, can a CMA perform a MWV under the direct supervision of a physician (on site but not in the room)? Many thanks, Joe




  78. HI,

    Can you bill TCM codes for a patient that resides in a NH or ALF? Also, can you bill a TCM performed at the patients home?


  79. Can the AWV G0438 be billed at a facility based clinic, or does it have to be billed as an “incident-to”? Thanks

  80. Scenario – patient comes in for an AWV (G0439). She also would like to have a pelvic/breast exam and obtain a pap smear for screening. Typically I would bill the G0439, along with the G0101 using ICD-9 V70.0 and V72.31 if they are done the same day. Would this be correct?

    Second scenario – Patient came in for an AWV (G0439), wanted a pelvic/breast/pap but provider did not have enough time to do these. If we bill for the G0439 (ICD-9 V70.0) that date of service, can we then bill for just the G0101 when the patient returns on another day for just the gynecological exam, and also use the V72.31?

  81. Hello Manny,
    Can you bill a depression screen (G0444)and an annual wellness exam together? Or is the depression separately billed?

  82. Manny,

    How do we bill for home health plan of care forms that we review and sign? Do you know how much medicare pays for this?

    • Mary —

      There are two G codes we use.

      G0180 – Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per certification period.

      Medicare National Payment: 41.48

      G0179 – Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per re-certification period

      Medicare National Payment: 53.99

      Check with your local Medicare carrier for their exact billing guidelines.

  83. One of our physicians has a patient who is diagnosed with Guillain-Barré. He sees the family of the patient to discuss the plan of care for the patient. Pt has BCBS and Medicaid. How do you bill for the visits?

  84. karen says:

    February 19, 2015 at 3:06 pm


    There is some differenc of opinion going on about where to add the -25 modifier. Scenerio #1. If a patient comes in for a cough and it is noted that they are eligible for a G0438; is the -25 modifier appended to the 99213 code or the G0438?
    Now reverse the scenario #2: If the patient comes in for only a G0438 and then seen by the physician due to say High blood pressure noted on the wellness visit; would the -25 still be appended to the 99213?
    We are being told that the -25 modifier needs to be appended to the G0438 if they are seen first for a wellness visit and then seen after for an acute visit. In my experience over the past year doing this – we are getting paid only when the -25 modifier is appended to the 99213/4 codes and not the G codes for the wellness visits. Thanks for your help

  85. Manny – I have just been informed that Medicare is no longer covering Bone Density Scans for screening purposes – (.i.e. postmenopausal women). No more V codes can be used. I do not see any updates in Medicare.gov regarding this. Do you have any information?
    Thank you so much.

    • Well that’s not very nice. Currently we do not have any clients doing scans so I was not aware of this. I don’t have any info on this but thanks for letting me know so I can check it out.

  86. Does the HRA need to be completed by the patient or can the nurse fill it out via verbal communication? Does the hard copy of this need to be in the EMR or can it be abstracted and destroyed?

    • No, the patient does not have to fill out your Health Risk Assessment form. The nurse or medical assistant can ask the patient the questions. The reason we have the patient fill out the form is so that we don’t take time away form the nurse. The nurse’s time can be better used helping other patients.

      I would scan a copy into the EHR. That way you have a record in the patients own hand if there are any questions in the future. An abstract with the all the answers covered should be fine.

      I would contact your malpractice provider and ask them what is the best practice for this would be.

      • Thank you, I have another question, let’s say a patient comes into our office for an AWV, she has a Medicare advantage plan that has a $500 deductible that she has not met yet. Durning the AWV she receives a prevar 13 vaccine, is that covered or does she have to pay because deductible hasn’t been met yet?

  87. Manny,

    There is some differenc of opinion going on about where to add the -25 modifier. Scenerio #1. If a patient comes in for a cough and it is noted that they are eligible for a G0438; is the -25 modifier appended to the 99213 code or the G0438?
    Now reverse the scenario #2: If the patient comes in for only a G0438 and then seen by the physician due to say High blood pressure noted on the wellness visit; would the -25 still be appended to the 99213?
    We are being told that the -25 modifier needs to be appended to the G0438 if they are seen first for a wellness visit and then seen after for an acute visit. In my experience over the past year doing this – we are getting paid only when the -25 modifier is appended to the 99213/4 codes and not the G codes for the wellness visits. Thanks for your help

  88. Sir,

    When a nursing home patient is seen primarily for L4 S1 decompression/fusion, can we use V45.4 as the primary diagnosis? If not, what is the alternative code ?


  89. Manny,

    Our practice sees patients in their homes using procedure codes 99342-99350. Could you provide me with the Medicare approved extended visit code for an extra 30-60 minutes of services in their home?
    Also, can you bill a Welcome to Medicare Visit (G042) or G0438/39 along with the above procedure codes (99342-99350)?

    Thank you for all your help.

    • Carleen —

      CPT code 99354, Prolonged service in office or other out patient setting 30-74 mins, is an add-on code that would be appropriate with the proper documentation. Medicare reimburses about $111 depending on your jurisdiction.

      I don’t see why would would not be able to bill a Welcome to Medicare or an Annual Wellness Visit along with your other E&M codes as long as you perform all the elements required. You could even bill a routine physical exam 99397/99387.

      Of course it is not covered by Medicare but some secondary insurance companies may pay or you could bill the patient directly for the physical.

      No need for an ABN for the physical but I would get a voluntary one anyway jut to inform the patient that they may be responsible in the end.

  90. Manny – I have just been informed that Medicare is no longer covering Bone Density Scans for screening purposes – (.i.e. postmenopausal women). No more V codes can be used. I do not see any updates in Medicare.gov regarding this. Do you have any information?
    Thank you so much.


  91. Hello Manny,

    If patient was with Dr A in 2013 and Dr A performed and billed initial AWV G4038. In 2015 the patient changed to Dr B. Dr B is not sure if the patient has ever had an AWV and patient forgot. Which code should Dr B bill?

    • Sarina if you were to unknowingly bill a G0438 becasue the patient had one previously, Medicare would let you know by denying the claim. You would then rebill will the G0439.

      Sometimes patients do forget they had an initial AWV. No way to know for sure unless you have the old medical records.

      Also don’t forget to get an ABN signed incase you have to bill the patient.

  92. Does anyone know if the Medicare Replacement plans are covering Zoster or Tetanus vaccines in the PCP office now – Original Medicare A/B requires them to be given at the pharmacy. Thank you.

    • Edna you will always get a denial from Medicare for 99387 as Preventative Routine Physical Exams are a non-covered service.

      The reason to bill Medicare is to get the denial and have it then sent to secondary to see if they will pay the 99387. Some secondary insurance companies do.

      If the secondary does not pay you can and should bill the patient.

    • Karen as you know all insurance policies are different so I can’t say if the patient has coverage.

      I would call Mutual of Omaha and give them the code to see if they offer coverage for a physical. But even then I would not trust them. They are an insurance company after all. LOL

      The best you can do is tell the patient that you will submit the claim and see what happens but that they may be ultimately responsible. Give the patient the option to have the service or not.

      • Don’t forget when talking about Plan F that it is a Medicare Supplement. Doesn’t matter what Company sells it, because an F is an F & the coverage is “Supplementing” Medicare. Therefore, if Medicare doesn’t cover something, the Supplement, in the case, Plan F won’t cover it. Medicare is the gatekeeper of decision making on approved procedures to begin with & if it’s not a Medicare approved procedure, the insurance company will never pay it.

  93. What Diagnosis code do I use if the patient has the 99397 and the G0438 or G0439 done on the same day.

    We currently use V70.0 which is utlized for a CPE (compelete physical) and V70.0 also is used for an Annual wellness visit if we are combining the visit into one encounter and using the modifier 25 – But if we want this to be two separate charges, is it ok to use V70.0 on both separate encounters?

    Thank you!

  94. Manny, I am just wondering if once a Medicare Supplement policy has been billed a AWV code; will the insurance also pay for a 99397 within the same 12 months? I have called some supplemental policies like UNC-AARP Medicare Solutions and they are covering #99397 and the MWV G0438/G0439?

    For instance, we have several patients that are getting covered for CPE (annual physicals) through the Medicare Supplemental programs; can they also have an AWV by the Nurse Specialist doing the AWV’s in the office after seeing the physician? An if so, Does it have to be two separate encounters?

    Thank you, Karen

    • Karen, yes you can bill both the CPE and the AWV on the same visit as they are two different services. If the patient has coverage for a 99397 both should be paid. Several of our practices do just that.

      Of course some supplemental policies don’t have coverage for the 99397. In that case we bill the patient directly after we see if the secondary pays.

    • Thank you! Are you aware of which Medicare supplemental policies do not cover both services? I know any standard Medicare A/B package does not cover 99397 and therefore we are doing the MWV with modifier if they see the physician as well for a routine visit. However, many Medicare patients are coming in with the newer replacement HMO/PPO plans that do cover 99397 which is great!

    • Thank you! Do you have a list of which Medicare Replacement programs will cover both the 99397 and Wellness Codes. G0438/9?

      Also when is it necessary to use the GY modifier?

      Thank you

      • Wondering if anyone has a list for Medicare Replacement Plans that cover both the 99xxx (annual physical) and Medicare AWV Wellness Codes (G codes). I know states/counties/plans are different but a starting place would be great.

  95. Manny –
    With a Medicare Cost Plan such as Rocky Mountain HMO, with Medicare being secondary, can you use G0439, or are they wanting a preventive charge such as 99397? Sometimes the provider uses a V70.0 ICD-9 code with their AWV and other times when providers are doing an AWV, they only put in codes such as 401.1, 496, etc. and do not use the V70.0(per Medicare guidelines stating “no specific diagnosis code”. Billers state the claim was denied when using the G0439 and want me (data entry) to change the code to 99397, that they don’t recognize the G-code. A bit confused with Medicare Cost Plans which code they are wanting? Can you clarify this? If the V70.0 diagnosis code is used, is this confusing the billing process?

    • Hello Carolyn —

      Yes Medicare does say “no specific diagnosis code” is associated with G0438 or G0439 but we find that they do like V70.0 which is the ICD-9 code that is used by all our practices.

      The problem with changing codes is that a 99397 is totally different than an AWV. If the provider actually performed an AWV then the documentation will not match a 99397.

      Check with the carrier on exactly how they want Annual Wellness Visits billed. Hope this helps.

    • Hey Carolyn, I’ve been billing for my doctor for a few months now and I have noticed claims gotten paid with v70.0 as the primary dx and also with specific dxs. Also, HMO plans replace medicare, so medicare does nothing as secondary. Finally, make sure what is the patient’s effective date with the insurance maybe he/she is due for their welcome to medicare visit (G0402) or maybe is the G0438 if they have never gotten a wellness visit before.
      Either way your best bet is to call the insurance and ask a representative to help you verify eligibility on CPT codes and give them the 9939_ and the G0439 to see what they say.

      Hope it helps!

  96. Such plans like WellCare, Careplus healthplans are they utilizing G0439 G0438? It appears like these plans are hit and miss. It gets frustrating. What do we bill, G codes or other preventative CPT codes?

      • Hi Mr Oliverez,

        Here in my doctor’s billing dptm we do a 99214 with a modifier 25 plus a Gcode and both get paid.
        We however use v70.0 as the primary and only dx for the Gcode, or we use the same specific dx we used for the 99214 for the Gcode too and it gets paid as well.

        *Important thing is to use the modifier 25 in the 99214 in order for both to get paid.

  97. Manny,

    I am still not sure:

    If a patient is new to me but not new to medicare:

    Do I bill G0438 automatically ( assuming they already had their welcome to medicare exam) or do I need to find out if they already had a G0438 and then bill a G0439?

    In other words is a G0438 a once in a lifetime code or a once per a doctor code?

    • once in a lifetime after their first 12 months of being enrolled with Medicare.

      Example: patient’s Medicare eligibility started in 11/20/13 and today is 11/18/14 and you are going to bill and submit claims today you are still able to bill a G0402.

      Example 2: patient’s Medicare eligibility started in 11/10/13 and today is 11/18/14 and you are going to bill and submit claims today you are still able to bill a G0438. then next year in 11/18/15 you would bill G0439 only every eligible year.

  98. HI can you please help me with this scenario

    Patient is here for G0439 and vaccines Q2037 and 90714. I know I have to use G0008 admin code for the flu but what would I use the TD admin? 90471 or 90472?

    • Chantal this is the way I would code the scenario:

      90714 with 90471
      Q2037 with G0008

      Medicare does not cover 90471, so unless the patient has a secondary insurance that will cover it, it may end up being patient responsibility.

      Hope this helps — Manny

      • Mr. Oliverez,
        How would secondary cover 90471 when Medicare initially writes it off (96 : Claim not-covered charges &M16)?
        Am I even allowed to go after patient for it if I have ABN?
        In one encounter I had G0439 90714with90471 and99214-25(dx: ulcer) and Medicare only paid for AWE and the level 4 visit. Basically TD vacc and the admin denied. How they expect providers to update pt with their imunization, admin the inj and then don’t get reimbursed for it?

        • Mahdi —

          Since you stated the patient came in for an AWV and had an ulcer I can only assume that there was no injury. The tetanus vaccine is only covered when there is an injury otherwise it is considered a preventative immunization that is no covered.

          Medicare considered the vaccine preventive and thus denied the claim.

          You do get reimbursed for the vaccine…..by the patient. Just bill them. No ABN needed since this was a non-covered service.

    • Sunny, no modifier is needed. The code should pay with no problem. What denial code are you getting from Medicare.

  99. Can we legally bill a G0101 visit without the Q0091? Just want to know because there is confusion in our office whether or not we can bill the annual well woman gynecological exam without doing a pap smear on the patient and whether or not Medicare will pay the G0101 if we don’t include the Q0091. Please help and let me know where I can find documentation on CMS.GOV or another reputable site.

    • Thelma —

      You should have no problem billing a G0101 without a Q0091. You are billing G0101 because the provider performed, and documented, at least 7 of the 11 elements of a Pelvic and Clinic Breast Examination.

      The pap smear does not need to be be done if it is not medically necessary. But if you do the smear, then it is appropriate to bill Q0091. If you look at the code descriptions you will see what each code includes. We have billed G0101 to Medicare for our OBGYN/Family Practice clients with no problems.

      There should be more information on the topic at http://www.acog.org and http://www.aapc.com both of which should reference CMS.

  100. Can you bill an office visit e/m code just for the V70.0 to Medicare? The problem I have is when we bill the preventive 99395 to Medicare it deny as non-covered, but the patient has Ohio Medicaid as secondary and will only pay the V70.0 if it is billed as an e/m office visit. most of the Medicaid secondary plans to pay for patient’s over age 20 for the annual visits. Could I use a modifier for Medicare to deny claim to bill to secondary for the 99214, 99215?

    • Hello Maria —

      No you cannot bill a problem orient office visit E/M code with V70.0, preventative care diagnosis, to Medicare. I am not familiar with the billing requirements for a physical with Ohio Medicaid and if they allow or want you to change the CPT code to a problem oriented E/M code. Just make sure you follow their guidelines to the letter.

      I do know some secondary commercial insurance companies do pay for the physical after Medicare denies it without changing anything. If the commercial secondary does not pay we would bill the patient the full amount since it was a non-covered service. There is not a modifier to use in this case.

      Sorry but I don’t think I am of much help to you in this case. –Manny

  101. Mr. Manny,
    I worked at primary care physicians, we billed Humana for Annual Wellness (G0438) and Office Visit Charge (99213/99214) and got paid last year and this year. Upon review, they retracted payment for G0438 for this year for denial reason that it is only paid once a year. reading your blogs/, now i understand that we should be using G0439 for subsequent Annuall Welness. If I corrected and resubmit the claims- could we get paid back for those dates/claims they’ve already retracted???

    • Marisa that is correct. G0438 is only ever billed 1 time. The first time you do an Initial AWV you bill G0438. At year 2 and every year thereafter that you bill the Subsequent AWV, G0439. G0438 is only ever billed 1 time. You should get paid for those once you submit a corrected claim if you don’t go beyond the timely filing limit. –Manny

  102. Hi Manny,
    Is there a documentation “Shortcut” for subsequent annual visits. For example, we have a unique 3 page form for our sAWV (HRA, sAWV, & Personalized Prevention Plan). Once done, next year there is often very little variation. Rather than rewrite all 3 pages, can we just update last year’s sAWV form and date it effective 11/14/2013? Would that suffice for an audit.

    • My understanding is that at the subsequent AWV G0439 you would just update the patient’s medical and family history, provider list, get new vital signs and weight, identify any cognitive impairment, update the screening schedule and risk factors list and provide advice. As far as what specific documentation would suffice for an audit, the more the better. I always encourage our doctors to document well especially with Medicare. I would make a new chart note referencing the initial AWV and documenting any updates. I would also initial, date and mark as reviewed the initial AWV visit, G0438, as a cross reference to the current visit. Check with your local Medicare carrier on their requirements.

  103. Manny
    As I explained before we have a digital instrument to produce that AWV on the field ,the instrument will generate a REPORT of the outcome containing the beneficiaries answers to the questionnaire signed by the patient and the licensed professional that performed the interview. In our case the AWV is ready to be billed with the GO 438. Now our system few day later will generate a complete digital Report of all the Health Risk finding and will generate also a TEMPLATE of the PPP requested that will easily assist the physician to prepare his PREVENTION PLAN and discuss it with their interviewed patient. WE plan to bill the AWV / GO438 as soon the visit is performed supported by the INITIAL generated report. Few days later when the OUTCOME OF THE AWV IS PROCCESED AND SCORED AND THE DIGITAL Prevention plan is finished and reviewed by our Prevention counsel the physician will bill a Prevention physician visit (99 code) and if is necessary WILL BILL any required Prevention Code in according with the outcome of the Health Risk factor finding, in order to achieve what Medicare want an adequate Prevention intervention with the AWV/HRA . I will like your valuable comment Thank you

          • Perfect! Thanks for getting back to me. Another thing, if they have a G0402, and a procedure of say, wart removal. Should you add a 25 to the G code? I wouldn’t think so because it is technically at HCPCS code, not a CPT code. What are your thoughts? Am I on the right track? I can’t find anything online.

          • Good questions Marcy. Typically we would add a 25 modifier to a problem orient visit that was coded with a G0402. For example:


            In your wart removal example I would put a 59 modifier on the removal. Now that said, insurance companies and your local Medicare carrier may have their own rules on how they want something billed. Best to check directly with them to find out how they want it billed.

            I know, not much help but there is one set of rules for proper coding and another set of rules that each insurance has on how they want a claim coded for payment.

  104. Dear Manny Our companies AWVRESEARCH&MANAGEMENT I CONTRACT WITH INTELLIGENT HEALTHCARE SOFWARE developed an unique digital HRA/AWV software tool that contain a battery clinical validated battery of test that strictly follow the CMS outline of the AWV/HRA. As its expressly mean HEALTH RISK ASSESSMENT our interactive program will be able to provide a comprehensive REPORT of the OUTCOMES indicating the HEALTH RISK FACTORS finding quantitative and qualitatively measured. The way how we selected the HEALTH TEST was trough a long year of SYSTEMATIC REVIEW of more than 5,000 clinical & credited test that fit on the AWV guideline. As you can understand our AWVQ1 proprietary digital tool will be a valuable component that a physician will have to perform the mandated AWV/PPP in compliance with regulation and effectively have a PERSONALIZED PREVENTION instrument that contain GLOBALLY an accurately all the possible HEALTH RISK that a patient may have.
    We been following since early last year your site and I came to the conclusion that will be worthy to have a meting with you to explore the possibility of getting your technical advice & assistance for our prospective medical professional clients in order to prevent any billing mistake when billing the GO438 or GO439. Please send me an email how to contact you and talk further about the idea.
    Thank you Dr. Edgar Hoffman COO

  105. Hey manny,

    Do you know if there is a code for a male rectal pap smear? i have used q0091 and 88160 but they keep getting denied due to sex not consistent to procedure.

  106. Manny,
    My docs are wanting to know about exact frequency of wellness exam for MCR patients. If patient had an exam in July 2012 and they want to get another one in May 2013, will that deny G0439 for frequency because we billed G0438 the year prior? Does MCR patient have to wait exactly 12 months or does it go by new calendar yr?

  107. I am so angry! I am disabled, and they now bill for the room and the doctor, almost double the charge! I cannot afford to see my doctor, and cannot afford a supplemental insurance! What the heck is going on? The billing dept., said anything to do with government charges, they have to bill you this new way! This government is hurting the ones who cannot afford it!!

  108. I read that you mention that commercial insurance cant be billed for G0438 why is that? Why would they be paying for this code if it was not allowed? Some of the Doctors I work with have been sending them to all insurances and they all pay for them.

  109. Our office was told b/c we are OB/GYN we don’t meet the qualifications to bill out G0438/G0439? Our docs have always done preventative and routine exams can you clarify?

    • Rose —

      Not sure who told you that OBGYN physicians could not bill for an Annual Wellness Visit but here is some info from Medicare.

      MLN Matters® Number: MM7079 Revised
      Related Change Request (CR) #: 7079
      Related CR Release Date: February 15, 2011
      Effective Date: January 1, 2011
      Related CR Transmittal #: R138BP and R2159CP
      Implementation Date: April 4, 2011

      Who is Eligible to Provide the AWV with PPPS?
      • A physician who is a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Social Security Act (the Act); or,
      • A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act); or,
      • A medical professional (including a health educator, registered dietitian, or nutrition professional or other licensed practitioner) or a team of such medical professionals, working under the direct supervision (as defined in CFR 410.32(b)(3)(ii)) of a physician as defined in the first bullet point of this section.

      Do some more research by contacting your local Medicare carrier.

  110. Getting G0439 denials this year with V70.0. Tried to be creative 🙂
    looks like sticking to 99213 or 99214 is wise this year. Do you jave the same issue? How did you go past it?

    • Sue I just talked to some of the team and they said they are not having any problems with getting G0439 paid. Looks like you have something odd going on there.

      We have had success billing G0439 with an Annual Routine Physical, 99397, with the occasional 99212 thrown in for a problem and got paid for all three on the same date of service.

      I would be careful with billing a 99213/99214 as a AWV as those codes are for problem oriented visits.

      What was the actual denial you got from Medicare?

      • How did you get paid for the 99397 from Medicare they dont accept those codes? If g0439 is only to be billed to Medicare then 99397 should not have been paid in that Date of service? Thank you

        • You are correct Andres that Medicare does not pay for a 99397 Annual Preventative Medicine Exam (or routine exam). But you can make the patient pay for the 99397. You don’t even need an ABN but I would recommend using one just to let the patient know they are responsible financially prior to the service.

          Remember a G0439 is NOT a routine exam. If you do a routine exam then you should bill 99397.

          An AWV is a wellness visit. The patient and doctor goes a series of required elements as listed below:

          – Medical and family history
          – List of current medical providers
          – Height, weight, BMI, BP and other appropriate routine measurements
          – Detection of cognitive impairment
          – Review risk factors
          – Review of functional ability
          – Establish a written screening schedule for next 5-10 years
          – Establish list of risk factors
          – Provide advice and referrals to health education and preventative counseling services
          – Other elements as determined by the Secretary of Health and Human Services

          Note that there is no mention of a physical exam because the AWV is not a routine exam as those are not covered by Medicare.

          Medicare allows you to bill for both a annual preventative medicine exam and the G0438 or G0439.

          If the patient is sick on the date of service you can even bill an E/M code for that service. The codes billed may look like this:


          Does this help?

  111. Is there a good way to explain to our Medicare patients why they get billed for the well woman exam ($80.00). They keep saying that they are calling Medicare who is telling them that our billing dept. should call them because we are coding it wrong (99397) and we need to change our code. They sign the ABN form when they come in and it states that the $80.00 is a non-covered charge and they will be liable but they are still not getting it. What would you advise I say to them.

    • Debra —
      There may be some confusion in terminology by your patients. A Well Woman Exam (also known as a Breast and Pelvic Exam) G0101 and Pap Smear Collection Q0091 are covered services from Medicare. A Routine Preventative Medicine Exam 99397/99387 (Some call it an Annual Physical) is not covered by Medicare and does not even need an ABN.

      Download our Billing Well Woman Exams to Medicare report. It will explain in detail how to bill for this exam and I believe it will give you information so you can come up with a script and possibly even a handout to explain to your patients how Medicare and the patient will be billed. The carve-outs tend to be tricky to patients.

      CLICK LINK TO GET REPORT: https://www.capturebilling.com/download-free-billing-a-well-woman-exam-to-medicare-special-report/

      Please let me know if this has been helpful or if you need more info and $80 is cheap – Manny

      • Hi Manny,

        I have question about, how should we bill G0438, G0101 and Q0091 on the same day.

        Where as G0438 is link to Dx code V70.0, G0101 and Q0091 is linked to V72.31. Whether we will get all the procedure paid or do will get denial as maximum benefit exhausted.

        I found this in Medicare Well women exam website stating:

        Question: Can you bill an annual with a V72.31 Annual Gynecological Exam diagnosis and get paid separately? No. If you have already billed out an annual in a given year (V70.0) then you cannot charge another annual with a different diagnosis.

        So, it’s quite confusing how to bill to Medicare insurance. In one of the claim we billed G0438- 25 modifier for DX:V70.0 and well women exam G0101 and Q0091 for dx: V72.31 and we received the payments for all the procedure.

        Can you please guide us, how we are suppose to bill two annual for same DOS. As you have mentioned we shouldn’t append 25 modifier for G code.

  112. I’m new to billing and I’ve been trying to get paid for the G0403 with the G0438. They will pay with the g0438 with dx V70.0, but they won’t pay for the g0403 with dx v70.0. So I refiled the G0403 with a medically necessary dx 414.01 and they still denied it. Help, am I doing something incorrectly?

    • Tyeisha, a routine EKG is a once in a lifetime service that must be furnished with the Welcome to Medicare Visit G0402 and cannot be done more than 12 months after the effective date of the patient’s enrollment into Medicare Part B. You will not get paid in the scenario you described above because a routine EKG is not a covered service. Basically you performed a free service and it needs to be written off per your Medicare remit. Sorry.

      Medicare only pays on EKGs if they are medically necessary with the appropriate problem oriented diagnosis code.

      So you cannot do routine EKGs on Medicare patients per the government. –Manny

  113. Hi
    Can we bill G0438 for non medicare patient like for UHC patient. Also does this service specific patient’s age. Please let me know


    • Saifee G0438 can only be utilized for billing Medicare patients, who are typically 65 years and older. The Annual Wellness Visit G codes cannot be used for commercial insurance.

      Please keep in mind that when billing G0438, there are key components which are required in order to be properly reimbursed by Medicare and are as follows:

      • Taking the patient’s history
      • Compiling a list of the patient’s current providers
      • Taking the patient’s vital signs, including height and weight
      • Reviewing the patient’s risk factor for depression
      • Identifying any cognitive impairment
      • Reviewing the patient’s functional ability and level of safety
      • Setting up a written patient screening schedule
      • Compiling a list of risk factors
      • Furnishing personalized health services and referrals, as needed

      Subsequent annual wellness visits, G0439, require that all the components above be updated and the doctor must also provide health advice to the patient as needed.

      Also remember that an AWV is not a Routine Physical Exam which can also be performed and billed to the patient.

      Let me know if this helps –Manny

  114. Thank you so much for sharing so much information on this complicated subject! As of today, we are receiving numerous take backs from Medicare for our Annual Wellness visits because the patient either had lab tests, xrays, or and EKG on the same day. They all were paid by Medicare at the time they were submitted, however, now they are taking back their monies on the AWV. I read the MLN CR 8153 and they stated they are taking back their money. I am not sure why they would on these types of visits? Has anyone else had this happen lately?

    Thank you!

  115. We have been billing a lot of the Annual Wellness visits G0438 and G0439 (dx: V70.0). We have also been doing an Evalualtion & Mgmt code 99213 with diagnostic codes with either of these visits, using a modifier 25 on the E& M code. But we have had deniels on the Depression Screening (G0444, dx: V70.0). We have tried it without a modifier and have resubmitted with 59 modifier on this code, also denied. Any suggestions for payment of the Depression Screening?

    • Alex if you look at MLN Matters Number MM7079 there are specific guidelines to billing for a specific place of service (POS) but there looks like there is no exclusion as to where the Annual Wellness Visit may be performed. I did find one reference from the University of Washington Physicians that actually gave the following POS codes that should be fine: 11, 12, 13, 22, 23, 71, 77, or 85.

      Check with your local Medicare carrier for their billing requirements –Manny

    • WHAT? Equivalent code?

      Could Medicare mean G0439? Maybe.
      Could Medicare mean G0402? Maybe.
      Could Medicare just be crazy? Probably.

      I ask some of our billers if they have ever had a denial like yours Anand and no one had.

      Sounds like Redetermination time. Let me know if you find out more information on the denial. –Manny

  116. We had a patient come in for the AWV, the patient also has hypertension and needed refills on meds, so an office visit was also billed at that time with a modifier 25. The physician also did an ear irrigation at that visit, code 69210. We were paid for each of the lines but now the medicare replacement insurance is trying to recover the amount paid on the well visit stating that it should not have been paid within the global period for CPT 69210. Should we have attached a modifier to the G0439 code?

  117. Alot of problems with medicare. Numerous claims being denied. When you call medicare you get put on hold and shuffled around. No one can seem to be able to answer any questions.

  118. I come across this blog on most searches I do on the AWV. I appreciate that you were on top of providing billing information and advice to physicians so quickly after the AWV became an option for physicians.

    • Thank you David. We are still educating doctors. Most providers I come across believe that a AWV is a full routine physical. I have another presentation next week with a large Family Practice to help train the physicians on the differences in the two services and how to document the AWV properly. I think i need to write a more detailed post. Thanks again –Manny

  119. My Dr billed me for a office/outpatient visit on the same day as my wellness visit
    (which they coded wrong I found seen seeing your website)
    are they allowed to do this?

    • Elizabeth, yes a provider can bill both an office visit and an AWV on the same day. They are two separate services with different documentation requirements. Medicare should pay for both services if billed properly. –Manny

    • Medicare should pay for both codes since they are different services. Make sure you have separate documentation for each service. Check with your local Medicare carrier for their billing requirements and the type of documentation needed especially for the G0439 Subsequent Annual Wellness Visit.

      Thanks for your question Pam –Manny

  120. By 12 months between the visits does it HAVE to be exactly 365 days or can they be seen for subsequent wellness visits if it’s within a week of their previous visit? How strict is the whole 12 month thing? We have just a few of our patient who have been scheduled for subsequent visits just shy of the 365 day mark. For routine annuals this was never a problem…

    • Kamara it has been our experience that if they say one year and you send in a claim that is only 364 day from the last visit that it will be denied. If it was my practice I think I would reschedule those patients for the following week to make sure the claim is not denied due to time limits.
      You are correct that for the routine annuals this was never a problem because those physicals (99387/99397) were and are still not covered by Medicare. So a patient could have two or more a year because it is a non-covered service that the patient is by statute responsible for.
      Remember if you are performing a Routine Annual Physical and an Annual Wellness Visit you are able to bill for both since they are two different services.

    • Elizabeth take a look at MLN Matters Number MM7079. This Medicare publication tells you the Providers that are eligible to perform a G0438 and G0439. Below is an excerpt from that publication. Looks like OBGYNs are OK.

      Who is Eligible to Provide the AWV with PPPS?
      • A physician who is a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Social Security Act (the Act); or,

      • A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act); or,

      • A medical professional (including a health educator, registered dietitian, or nutrition professional or other licensed practitioner) or a team of such medical professionals, working under the direct supervision (as defined in CFR 410.32(b)(3)(ii)) of a physician as defined in the first bullet point of this section.

      — Manny

      • The provider must be the Primary Care Physician though or else someone isnt' getting paid and claims will be duplicated or more between various offices.
        If a patient has a PCP and sees the OB/GYN for the bi-annual Pap then they should not be coding for the AWV. These should be done by the PCP and not the specialist.
        We are having to appeal a situation right now and the specialist office coded for the AWV last year. We did not know coded for their AWV-initial and our visit is being denied. Medicare specifically asked the patient who was PCP and did the specialist go through certain questions. PCP did but specialist only saw them for the specialty issue.

  121. We will be doing an annual routine physical exam for this patient and the coding that we are planning on using is 99335-25 G0439 for the cpt we have dx code V70.0 for the g0439 and 472.0, 401.9, 438.85 for the 99335

    • You would need to bill the appropriate Annual Routine Physical Exam that you are doing with the appropriate code such as 99397 with a V70.0. You did not say you were doing an Annual Wellness Visit so you should not be using G0439. If you are also doing an Annual Wellness Visit (Subsequent) in addition to the Annual Routine Physical Exam you can bill for both. The applicable diagnoses for 99335 should really be the medically necessary diagnoses – not the V70.0 since 99335 is for a problem oriented visit in a rest home.

      Based on only the information provided, and if you are also performing an AWV, I think this is what you may want to look at billing to Blue Cross and then to the Medicare Secondary:

      99397 V70.0
      99335-25 472.0, 401.9, 438.85
      G0439 V70.0

      Please be sure that the documentation requirements are met for all services provided and check the coding guidelines of the carriers. Also remember that Medicare does not cover Annual Routine Physical Exams so if BCBS holds the patient responsible for a copay or co-insurance, bill the patient. — Manny

  122. Manny if a patient has BC/BS as primary and Medicare as secondary could we possibly bill out the G0438/G0439 code?

  123. Hi Manny,

    Please help me identify the following cpt coding for: 1) DepoMedrol 20mg 2) DepoMedro 40mg 3) DepoMrol 80mg. 4) Does the injection code 90471 apply?


    • The codes for Depo-Medrol (methylprednisolone acetate) can be found in the current edition of the HCPCS Level II coding book. Look at Appendix 1 – Table of Drug and Biologicals to find Depo-Medrol in the alphabetical listings. There you will find the drug name, unit, route and J code. Once you have the J code find the description in the Drugs Administered Other Than Oral Method section of the coding book. Make sure that the description matches what you are giving the patient.

      J1020 Depo-Medrol 20 mg
      J1030 Depo-Medrol 40 mg
      J1040 Depo-Medrol 80 mg

      CPT code 90471, immunization administration, does not apply in this case because Depo-Medrol is not a vaccine. A better code to use would be 96372 , Therapeutic, prophylactic, or diagnostic injection, subcutaneous(SQ) or intramuscular(IM).

      Hope this helps. –Manny

  124. We have a situation where we are trying to figure out how to bill a NP to our office, but not new to Medicare. The PT has already had their welcome to Medicare exam G0402. We are trying to decide if we should bill with G0438 or G0439. Logically, I believe we should bill with the subsequent. But with this PT being new to the office, that is where I am getting thrown off my train of thought. Please help.

    • An Annual Wellness Visit is not subsequent to the G0402, Welcome to Medicare exam. Billing a G0438, Initial AWV is appropriate. You should not bill a subsequent AWV without the initial. I know you said logically but this is Medicare. And remember that an AWV is not a Routine Preventative Exam so if you perform a 99387 and document it you can bill the patient. Both can be done on the same day. Check with your local Medicare carrier for detailed information on billing these visits. Hope this helps –Manny

  125. If a patient see their physician for their once in a life time IPPE Initial Preventive Physical Exam and 12 months later come back to see their physician for their AWV (Annual Wellness Visit), do we bill the initial G0438 (first visit, once in a lifetime visit) or do we bill the subsequent visit of (G0439)?

  126. Hi Manny, I got confused a little. Patients is eligible for AWN G0438 ONLY in the second year of Medicare coverage? or during the lifetime as long as 12 month has passed since IPPE ( if pt is eligible) and AWN has not been billed before. For example if patient has Medicare Part B effective on 01/01/2003 and was never billed for AWN G0438 before, can I bill G0438 for 2011 visit?

    • Irina thanks for your question.

      The G0438 Annual Wellness Visit can be billed out at any time if the patient has never been seen for the AWV and it is after the first 12 months the patient became a Medicare recipient. For example, if the patient has had Medicare coverage since 2009 but the AWV has never been billed then use the G0438 code, not the G0439 Subsequent visit (as there was no prior G0438 for the G0439 to be subsequent to). There is no time limitation to the G0438 unlike the G0402 IPPE ("Welcome to Medicare" exam) and it’s corresponding once in a lifetime benefits.

      As always please be sure to check with your MAC and the guidelines at CMS: http://www.cms.gov/Outreach-and-Education/Medicar

      Hope this helps –Manny

  127. (con't from previous comment)
    I did a little research and discovered the following on the Medicare.gov web site under "Welcome to Medicare Preventative Visit" where it discusses "Your costs in Original Medicare": "You pay nothing for the yearly 'wellness' visit if the doctor or other health care provider accepts assignment. If you get additional tests or services during the same visit that aren't covered under these preventative benefits, you may have tp pay coinsurance, and the Part B deductible may apply." What is there in either a CMT G0438 or G0439 exam that is not covered in a CMT 99397 exam; and, why wouldn't I just be billed for whatever a CMT 99397 exam covers that is above and beyond the scope of a G0438 or G0439 exam? Am I being defrauded by my medical service provider, or am I just dealing with a coding department that is merely ignorant?

    • Mark, great question. I started to reply here in this comment tread but soon realized I needed more space to write so I put in into a post. Click on this link: https://www.capturebilling.com/am-i-just-dealing-w… . This will take you to the post where I attempt to answer your question. If I did not hit the mark please leave follow up questions and your comments on that post. Thanks again for your question. –Manny

  128. (con't from previous comment)
    When I asked them why they didn't bill Medicare for a Wellness Exam, which I subsequently learned they would have billed under CMT G0439, I was informed that because I had received a CMT 99397 physical they couldn't bill Medicare for a Wellness Exam and then bill Tricare4Life and me for the additional services over and above the Welness Exam, as that would be considered fraudulent. I then asked what Medicare would have billed for the Wellness Exam and was told $254.00.

  129. In November 2011 I scheduled a Wellness Exam after receiving a notice from Medicare. I turned 65 on November 16, 2010, so this was my initial notice. My physician explained the limited scope of the exam and recommended that I get a full physical, which I agreed to. Last month I received a bill for approximately half, $116.87, of the total $228.00; Tricare4Life picked up the balance of $111.13. I called the billing office and asked them why Medicare had not been billed for any part of the exam. I was informed that Medicare will not pay any part of the CMT 99397 physical.

  130. The word "wellness" throws us because most of our pts have a health issues. That's why they come to the Dr. to get help managing their illnesses. The preventative exam doesn't fit either: if they'd practiced preventative measures long ago, they probably wouldn't have diabetes, htn, hi-cholesterol, etc. Yet bill 99215 to Medicare for annual review of all their issues and make medication adjustments and do lab reviews, and EKG, etc, and the pt calls when they get the statement after Medicare's paid and they want their visit "rebilled with the wellness code — it's free. Medicare said so." Most of the elements for the G4038/G4039 are covered in the 99215 but there was so much that was medically necessary. It's hard to find a code that everyone's happy with, from pt to Dr. to biller!

  131. I am having problems with the medicare hmo’s more than anything. This is what I am billing the HMO–g0439 dx v70.0, g0403 dx v17.3, g0328qw dx v76.41, g0101 59 dx v72.31. I am getting a denial stating the procedure code is inconsistent with the modifier used or a required modifier is missing and the benefit for this service is included in the payment/allowance for another service/procedure. Help!!! We typically bill our preventative medicine visits as g0438 or g0439 and g0403, g0328 and if applicable g0101 59. Any suggestions?

    • Jenny, to try to help better answer your question, I will respond to each individually billed charge you mentioned:

      G0439 / V70.0 This billing seems appropriate. If this particular line item is denied then I would suggest double checking the frequency and date of coverage of the patient (for example, should this have been billed as a G0438 initial AWV instead, or as a G0402 IPPE?). Otherwise we frequently bill this out just as you have listed and receive reimbursement.

      G0403 / V17.3 The only appropriate time to bill out the EKG as a G0403 is in conjunction with the G0402 IPPE “Welcome to Medicare” exam. It is a once in a lifetime benefit. If a patient is seen for the AWV and the provider also performs an EKG we will bill out the EKG as a 93000 with a diagnosis that indicates the medical necessity of the EKG. For one of our Medicare Carrier’s there is a list of diagnosis codes that supports medical necessity. Please check your carrier’s website to find a list of appropriate diagnoses. Here is a link to one of our local carriers: https://www.novitas-solutions.com/policy/mac-ab/l…. Dx code V17.3 is not on this list.

      G0328-QW / V76.41 There are specific rules, please check CMS or your MAC website. Is CPT code 82270 (Stool Occult Blood) a more appropriate code for you to use? You may want to look into it. Also look at V76.51 (Screening for Colon Cancer). Please see the following link for additional information and note that CMS also indicates to contact the local Medicare Contractor for guidance for both the G0328 and the 82270: http://www.cms.gov/Outreach-and-Education/Medicar….

      G0101-59 dx v72.31. The Medicare Pelvic and Breast Exam G0101 has very specific billing guidelines: http://www.cms.gov/Outreach-and-Education/Medicar…. Although this code as listed on the quick reference chart can be billed with the V72.31, we’ve found that our Medicare Carrier does not accept this dx and requires any of the other diagnoses instead (V76.2, V76.47, V76.49). Please be sure to check with your local carrier.

      ***As always with billing Medicare for preventive services be sure to have the proper ABN completed, signed and dated.

      You can see why there is a trend for doctors to have Certified Professional Coders on staff and why practices are outsourcing their medical billing. Medicare is making it more complicated every day for medical practices. –Manny

  132. What is the appropriate billing for care plans and the recerts. We are having trouble getting Medicare to pay anything on these. Can someone give me advice on what icd9 and cpt codes you are using?

    • We do have clients that we do billing for and have the following pointers for you:

      Appropriate billing codes for Home Health Certificates: G0180
      *Dx codes are used in order that is on the Home Health Certificate
      *Also the home health agency # that is on the right hand side of the certificate, must go in box 23 of your claim form, if not it will reject.
      *The DOS must be the date that is the start date on the Homehealth Cert .

      Home Health Recerts (G0179) do not pay with our local carrier so we do not bill for them.

      The home health certification days are 12/29/2012-02/26/2013.
      The Doctor fills out another one on 02/27/2013.
      You would bill another G0180 for DOS 02/27/2013.
      You may only bill and be paid for 1 certification during the certification dates dates.
      Even if the patient switches agencies, Medicare only allows payment every 60 days.

      If there is an addendum or change of care plan, it is inclusive and you may not bill for it, hence why we do not bill G0179.

      We found the following information on our local Medicare carrier (Novitas) which has some great information about billing and the requirements for Care Plan and Certifications/Recerts.

      Novitas website: https://www.novitas-solutions.com/em/coding.html see Physician Care Plan Oversight Services and Physician Certification and Recertification of Home Health Services. Make sure to check with your local Medicare carrier for specific rules in your jurisdiction.

  133. I'm having the same issue as Christine. We are billing G0438 and 99214 with 25 modifier and getting them all denied. We billed with V70.0 as the primary dx code. Medicare is no help at all on clarification. Do I have to have v70.0 secondary?

    • We have not had this denied as long as everything is billed properly with appropriate modifiers and diagnoses. We frequently bill out either the G0438/G0439 V70.0 with an office visit with modifier 25 for additional distinct problems. We are reimbursed by Medicare for both the AWV and an office visit if billed out properly.

      However, we have come across the following problems:

      Billing out either the AWV or IPPE and getting a denial for not using the appropriate CPT code. For example we billed out a G0438 but it should have been a G0439, patient was seen and billed for the G0438 by another provider. We corrected the claim and received payment. Also we had billed out a G0438 but should have billed out the G0402 instead, corrected and got this reimbursed by Medicare. Note that we billed these all with the V70.0.

      Also frequency/date of service could be an issue – have you double checked the dates of service between the G0438 and G0439, or between the G0402 and the G0438?

      What is the exact denial code that you are getting on the EOBs?

      We have found the carrier websites to be very helpful. In our area we bill out to both Trailblazer and Novitas. Have you had any luck contacting your local carrier provider representative?

      Also see the CMS website and Guide to Medicare Preventive Services.

      • Manny,
        I am having a similar problem where I billed out an AWV and a 99204. Medicare paid the 99204 but said the G0438 was mutually exclusive. Any thoughts?

        This is how I billed it:
        V70.0 – G0438
        715.96, 780.52, 401.9 – 99204-25


        • Valerie, there has got to be more to this Annual Wellness Visit (AWV) denial because the way you have it coded should pay. We have no problem getting paid for claims that are similarly coded.

          What was the denial code you received from Medicare? It could be something as simple as frequency (since this is a new patient to your practice they could have had the G0438 with another provider and you need to bill out the G0439 instead) or missing a referring physician, etc.

          Let me know what you find. –Manny

          • It's a United Healthcare Medicare policy. I just called them about it to see if they can explain the denial in more detail and all she could tell me is that the G0438 is mutually exclusive to the 99204-25.

  134. A provider has ordered labs on a patient that will be seen on his 65th birthday for the Initial Medicare Wellness visit. What diagnosis does the provider use for these labs? Medicare will not accept the V70.0 code.

    • As labs are not considered a part of the IPPE or AWV submitting them with the V70.0 and not showing medical necessity would definitely result in a denial for non covered, routine services. As Medicare has such stringent requirements for billing, the labs can only be billed if medical necessary and appropriate versus any annual code, based on their documentation.

  135. Hi, the dr. that I bill for wants to bill a G0439 with and office visit 99213 using a 25 modifier. I called medicare and they said I can't do this but the doctor insists this will get paid. Have you ever heard of this?

    • We have never heard of this being denied as long as everything is billed properly with appropriate modifiers and diagnoses. We frequently bill out either the G0438/G0439 with an office visit with modifier 25 for additional distinct problems. We are reimbursed by Medicare for both the AWV and an office visit if billed out properly.

  136. Hey Manny so im setting up a patient for G0438. Can I just bill this with dx V70.0 or do I have to use a cpt code 99385-99387 with that? Also if both need to be used do I have to add a modifier 25?

    • Yes you can bill G0438 with V70.0. If you are also performing a Routine Preventative Medicine Physical Exam for a Medicare patient (which is different than the Annual Wellness Visit-G0438) you can bill the age appropriate 99387 or 99397 CPT code also with a V70.0 diagnosis. A modifier 25 is not needed. Check with your local Medicare carrier for their specific rules.

      • Medicare does not recognize the 99387 or 99397 code, G0438 is this Preventive replacement code. You are incorrect Wellness and Preventive are the same.

        • Tricia you are correct that Medicare does not cover 99387 (new patient) or 99397 (established patient) Routine Preventative Medicine Exams, typically referred to as Annual Physicals. If this non-covered services is performed the Medicare patient can be billed directly and an Advanced Beneficiary Notice (ABN) is not needed. Note that some secondary insurance companies do cover the routine physical.

          Many providers believe that the Annual Wellness Visit (AWV, G0438 and G0439) is the same as a Routine Preventative Exam. My guess is they are going by what they may have heard in the media that Medicare covers check-ups. The media has been misinforming doctors and patients. A Routine Preventative Exam and AWV are two different services. The AWV has very specific questions that a providers must ask and properly document in order to be able to bill for the service. Take a close look at the requirements in the CMS MLN Matters Publication MN7079 and then take a look at the requirements for 99387/99389 Routine Physical in your CPT book and you will be able to see that the two services are completely different.

          I foresee providers documenting the AWV as a Routine Physical and not documenting what is required by the AWV, getting audited and having to return the money (plus penalties) to Medicare because the documentation does not support the G0438 coding.

          If your physicians are performing both a 99387/99397 and a G0438/G0439 t