Medicare Wellness Visit Billing
For a 65-year-old patient with Medicare supplemental insurance, you should bill using Medicare-specific G-code G0438 for the initial Annual Wellness Visit (AWV) or G0439 for subsequent annual visits—never use standard preventive care codes (99381-99397), as Medicare does not reimburse these codes for wellness visits. 1
Correct Billing Codes for Medicare Wellness Visits
- Use G0438 for the initial "Welcome to Medicare" preventive visit or first AWV 2, 1
- Use G0439 for subsequent annual wellness visits in following years 2, 1
- Do NOT bill standard preventive care codes (99381-99397), as Medicare specifically does not reimburse these codes for wellness visits 1
When You Can Bill Additional Services
If the visit becomes medically complex and requires significant problem-focused evaluation beyond the wellness visit scope, you can bill an additional evaluation and management (E/M) code (99212-99215) alongside the wellness visit code using modifier 25 1
Additional Billable Services During the Same Visit:
- Cognitive or developmental screening (CPT 96110) can be added with an appropriate modifier 1
- Separate E/M services for acute or chronic disease management can be billed with modifier 25 when documentation supports the additional complexity and time spent 3, 1
- The American Academy of Family Physicians confirms that modifier 25 should be used on the wellness visit code when billing a separate E/M service on the same day 1
Critical Documentation Requirements
Your documentation must clearly distinguish between the wellness visit components and any additional problem-focused care to justify billing both codes 1. The wellness visit focuses on health risk assessment, personalized prevention planning, and screening for cognitive impairment—not comprehensive physical examinations 1, 4
Key Components That Must Be Documented for AWV:
- Comprehensive health risk assessment including medical and family history 2, 4
- Medication review of all prescription and over-the-counter medications 2, 4
- Cognitive screening using validated tools 2, 4
- Immunization status verification 2, 4
- Screening for geriatric syndromes including falls risk, depression, and functional status 2
- Social determinants of health assessment 2, 4
- Personalized prevention plan based on identified risk factors 4
Common Billing Pitfalls to Avoid
- Never substitute a brief physical examination for the comprehensive preventive services that Medicare covers and expects 2, 4
- Do not neglect cognitive screening—this is a required component that can increase detection rates two to threefold 2
- Ensure you're using G-codes, not CPT preventive codes, as this is the most common billing error for Medicare wellness visits 1
- Document time spent if billing based on time for any additional E/M services, ensuring documentation supports the level of care and complexity 3
Medicare Supplemental Insurance Considerations
For patients with Medicare supplemental insurance (Medigap), the supplemental plan typically covers any copayments or deductibles that Medicare Part B doesn't cover for the AWV 3. The primary billing should still go through Medicare using the G-codes, with the supplemental insurance covering any patient responsibility 3.