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CPT G0438

Initial Annual Wellness Visit

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 from the conversation itself.

Common Diagnoses

Z00.00

Related Specialties

primary careinternal medicinegeriatrics

Related Procedures

CPT 993951.50 work RVU

Annual Physical 18-39

CPT 993961.75 work RVU

Annual Physical 40-64

CPT G04391.50 work RVU

Subsequent AWV

CPT 992131.30 work RVU

Office Visit Level 3

CPT G0438: Initial Annual Wellness Visit

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.

Related Procedures

  • CPT 99395: Annual Physical 18-39
  • CPT 99396: Annual Physical 40-64
  • CPT G0439: Subsequent AWV
  • CPT 99213: Office Visit Level 3

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