CPT G0438

Initial Annual Wellness Visit

Initial Medicare Annual Wellness Visit with personalized prevention plan.

45-60 minutes
2.43 work RVU
5 requirements

Documentation Requirements

  1. 1Health Risk Assessment (HRA)
  2. 2Medical and family history review
  3. 3List of current providers and medications
  4. 4Cognitive impairment screening
  5. 5Personalized Prevention Plan Services (PPPS)

Billing Tips

  • •Medicare-specific code, not for commercial insurance
  • •Patient must not have had AWV in past 12 months
  • •Can bill with E&M using modifier 25 for separate problem
  • •Document all required AWV elements

Frequently Asked Questions

What is required for a complete AWV?

AWV requires: Health Risk Assessment, medical/family history review, current provider list, cognitive screening, depression screening, functional assessment, and Personalized Prevention Plan.

Automate Initial AWV Documentation

Scribeable captures all required elements for CPT G0438 from your patient conversation. Generate compliant notes in seconds.

Common Diagnoses

Z00.00

Related Specialties

primary careinternal medicinegeriatrics

Related Procedures

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Annual Physical 18-39

Comprehensive preventive medicine evaluation for adults 18-39.

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Annual Physical 40-64

Comprehensive preventive medicine evaluation for adults 40-64.

CPT 992131.30 work RVU

Office Visit Level 3

Established patient office visit with low level of medical decision making.

CPT 992141.92 work RVU

Office Visit Level 4

Established patient office visit with moderate level of medical decision making.

CPT G0438: Initial Annual Wellness Visit

Initial Medicare Annual Wellness Visit with personalized prevention plan.

Documentation Requirements

  1. Health Risk Assessment (HRA)
  2. Medical and family history review
  3. List of current providers and medications
  4. Cognitive impairment screening
  5. Personalized Prevention Plan Services (PPPS)

Billing Tips

  • Medicare-specific code, not for commercial insurance
  • Patient must not have had AWV in past 12 months
  • Can bill with E&M using modifier 25 for separate problem
  • Document all required AWV elements

Frequently Asked Questions

What is required for a complete AWV?

AWV requires: Health Risk Assessment, medical/family history review, current provider list, cognitive screening, depression screening, functional assessment, and Personalized Prevention Plan.

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Getting Started