Medicare Initial Wellness Visit Billing Code
For the initial Medicare wellness visit for a new beneficiary, use HCPCS code G0402 ("Welcome to Medicare" preventive visit) if performed within the first 12 months of Medicare Part B enrollment, or G0438 (Initial Annual Wellness Visit) if performed after the first 12 months of enrollment.
Understanding the Two Types of Initial Wellness Visits
Medicare provides two distinct initial preventive visit codes depending on timing of enrollment:
Welcome to Medicare Visit (G0402)
- When to use: Within the first 12 months after the beneficiary's Medicare Part B coverage begins
- One-time benefit: Can only be billed once per beneficiary
- Purpose: Initial comprehensive preventive assessment for new Medicare enrollees 1, 2
Initial Annual Wellness Visit (G0438)
- When to use: After the first 12 months of Medicare Part B enrollment, if the beneficiary has never received an Annual Wellness Visit
- Purpose: Establishes baseline health status and creates personalized prevention plan 1, 2
Key Billing Requirements
Both visits require specific documentation elements:
Required components include:
- Health Risk Assessment completion
- Review of medical and family history
- Measurement of height, weight, blood pressure, and BMI
- Detection of cognitive impairment
- Review of functional ability and safety
- Establishment of a written screening schedule
- List of current providers and suppliers
- Creation of personalized prevention plan 1, 2
Common Pitfalls to Avoid
Do not confuse these with standard E/M codes: The wellness visits (G0402, G0438) are distinct from office visit codes (99201-99205 for new patients or 99211-99215 for established patients). The wellness visits focus on prevention and screening, not acute or chronic disease management 3.
Cannot bill both on same day: If addressing acute problems during a wellness visit, you may bill a separate E/M code with modifier 25, but the wellness visit itself must meet all required elements 1.
Time allocation matters: These visits typically require 60-90 minutes for proper completion. Inadequate time allocation leads to incomplete documentation and claim denials 1, 4.
Reimbursement Considerations
The maximum reimbursement for initial wellness visits is approximately $159-174 depending on geographic location and year 4. These visits are covered at 100% by Medicare Part B with no patient cost-sharing when properly coded and documented 1, 2.
Team-based approach: Clinical staff can perform many required elements (health risk assessment, vital signs, screening questionnaires), with the physician or qualified practitioner reviewing and creating the prevention plan. This improves efficiency and ensures all required components are completed 1, 4.