HCPCS G0438: Initial Medicare Annual Wellness Visit — $174 Rate, Once-Per-Lifetime Rules (2026).
HCPCS G0438 is the Medicare billing code for the initial Annual Wellness Visit (AWV) — a preventive visit focused on building a personalized prevention plan, not a physical exam. It can be billed once per patient lifetime, and only after the patient has been enrolled in Medicare Part B for more than 12 months (during the first 12 months, the Welcome to Medicare visit G0402 applies instead). Medicare covers G0438 at 100% with no deductible or coinsurance when billed as a standalone preventive visit.
Quick Answer
What is HCPCS G0438?
HCPCS G0438 is the Medicare code for the initial Annual Wellness Visit, reimbursing approximately $174 in 2026 with no patient cost-sharing. It is billable once per patient lifetime, and only after the patient's first 12 months of Medicare Part B enrollment (the first year belongs to the Welcome to Medicare visit, G0402). The visit requires a health risk assessment, cognitive and depression screening, functional and safety screening, and a written 5-10 year prevention plan — but no physical exam and no minimum time. Subsequent annual visits are billed as G0439 (~$138), starting 11 full months later.
Documentation
Documentation requirements.
Health Risk Assessment (HRA) completed by or with the patient, covering demographics, self-assessed health status, psychosocial and behavioral risks, and activities of daily living
Medical and family history, including a review of social determinants of health risk factors
Current providers, suppliers, and medications list (including supplements)
Height, weight, BMI, and blood pressure measurements
Cognitive impairment detection by direct observation or a structured tool, with the method documented
Depression screening using a standardized instrument (e.g., PHQ-2/PHQ-9)
Functional ability and safety screening — fall risk, hearing, home safety, ability to perform ADLs
Written 5-10 year screening schedule (personalized prevention plan) provided to the patient
List of identified risk factors with recommended interventions and referrals, including personalized health advice
Billing Workflow
How to bill G0438, step by step.
The calendar-month workflow a billing team actually runs — from qualifying the month to the increment math at month close.
Verify AWV eligibility before scheduling
Run the patient through your MAC portal or eligibility vendor (HETS-based checks show the next AWV-eligible date). Confirm more than 12 months of Part B enrollment and no G0438 on file from any provider. Transferred patients are the trap — their AWV history lives at the old practice.
Send the HRA ahead of the visit
The Health Risk Assessment can be completed by the patient before or during the visit. Sending it ahead (portal, mail, or phone outreach) shortens the visit and improves completion — the HRA is a required element, not an optional add-on.
Complete and document every required element
History, providers and medications list, vitals with BMI, cognitive impairment detection, depression screen, functional and safety screening, and the written 5-10 year prevention schedule. The AWV has no minimum time, but a missing element makes the whole visit non-billable.
Offer Advance Care Planning as a same-day add-on
ACP (CPT 99497) furnished on the same day as an AWV, by the same provider, waives the patient's ACP deductible and coinsurance — the only day ACP is free to the patient. Document voluntary consent and the minutes spent.
Use the AWV as the chronic-care initiating visit
For patients new to the practice or not seen within the last 12 months, CMS requires an initiating visit (AWV, IPPE, or comprehensive E/M) before CCM or PCM can begin. Capture CCM/PCM consent during the AWV and enrollment starts the same day — the AWV pays ~$174 and opens ~$62+/month in care-management revenue.
Submit with the correct visit hierarchy
Bill G0438 as the primary preventive service. Append modifier 25 to any separately identifiable same-day E/M. Do not bill G0438 with G0402 (IPPE) on the same day, and never re-bill G0438 for a patient with one on file anywhere.
Scenarios
Common billing scenarios.
First AWV in the patient's 14th month of Part B
BillableA patient enrolled in Medicare Part B 14 months ago and has never had an AWV with any provider. The practice completes the HRA, all required elements, and the written prevention plan. Bill G0438 — the patient is past the first-12-months IPPE window and has no prior AWV on file.
AWV during the first 12 months of Part B
Not BillableA patient enrolled in Part B 8 months ago requests a wellness visit. G0438 is not billable during the first 12 months of Part B enrollment — that window belongs to the Welcome to Medicare visit (IPPE, G0402). The claim will deny; schedule the IPPE now or the AWV after month 12.
Patient had an initial AWV at a previous practice
Not BillableA new patient transfers in. Their eligibility check shows a G0438 billed by another practice three years ago. G0438 is once per lifetime across all providers — bill the subsequent visit G0439 instead. Billing a second G0438 is one of the most common AWV denials.
AWV plus a same-day problem-focused E/M
BillableDuring a scheduled initial AWV the patient raises uncontrolled knee pain, and the provider performs a separately identifiable, medically necessary evaluation. Bill G0438 plus the E/M code with modifier 25. The AWV itself carries no cost-sharing, but the E/M portion is subject to the patient's normal deductible and coinsurance — set that expectation before the visit.
Audit & Compliance
Audit rules & denial defense for G0438.
What a payer reviewer checks on a records request, the failure that triggers each denial, and the documentation that survives it.
Once-per-lifetime status verified across providers
Denial risk
Second-lifetime G0438 claims deny automatically, and repeated attempts flag the practice for prepayment review
What survives review
Eligibility-check response saved to the chart showing no prior AWV at the time of service
All required elements present in the note
Denial risk
Records requests that find no cognitive assessment, no depression screen, or no written prevention plan reclassify the visit as non-billable
What survives review
A structured AWV template whose sections mirror the CMS element list, with the patient-facing prevention schedule saved as a chart artifact
Same-day E/M is separately identifiable
Denial risk
Modifier-25 E/M claims on AWV days are a standing audit target — reviewers look for E/M notes that restate AWV elements
What survives review
A distinct E/M note documenting the presenting problem, exam, and medical decision-making beyond the preventive elements
Supervision documented for clinical-staff visits
Denial risk
AWVs furnished by an RN or health educator without documented direct physician supervision fail incident-to review
What survives review
Supervising physician identified in the note, present in the office suite, with the supervision relationship stated
FAQ
Common questions about HCPCS G0438.
What is HCPCS G0438?
G0438 is the Medicare billing code for the initial Annual Wellness Visit — a preventive visit that builds a personalized prevention plan. It is billable once per patient lifetime, only after the first 12 months of Medicare Part B enrollment, and reimburses approximately $174 in 2026 with no patient cost-sharing.
How much does G0438 reimburse in 2026?
Approximately $174 nationally under the 2026 Medicare Physician Fee Schedule, with no deductible or coinsurance for the patient. The exact amount varies by locality (GPCI adjustment). The subsequent-year visit, G0439, reimburses approximately $138.
What is the difference between G0402, G0438, and G0439?
G0402 is the Welcome to Medicare visit (IPPE), available only during the first 12 months of Part B enrollment. G0438 is the initial Annual Wellness Visit, available after those first 12 months, once per lifetime. G0439 is the subsequent AWV, billable every year thereafter — at least 11 full months after the last AWV.
Is the Annual Wellness Visit the same as an annual physical?
No — and the confusion causes real billing problems. The AWV is a prevention-planning visit: health risk assessment, screenings, and a written prevention schedule. It does not include a head-to-toe physical exam, and Medicare does not cover routine annual physicals at all. If the provider also addresses a medical problem, that portion is billed as a separate E/M with modifier 25 and normal cost-sharing.
What happens if the patient already had an AWV at another practice?
G0438 is once per lifetime across all providers, not per practice. If any provider has billed G0438 for the patient, bill G0439 for the visit instead. Run an eligibility check before the appointment — it shows the patient's AWV history and next eligible date.
Who can perform the AWV?
A physician, PA, NP, or CNS — or, distinctively for the AWV, a medical professional such as an RN, health educator, or registered dietitian working under the direct supervision of a physician. This makes the AWV one of the few Medicare visits a practice can staff without consuming physician time.
Related Codes
Other CPT codes.
CCM Initial 20 Minutes
$62.00 • Once per calendar month
RPM Device Supply (16+ Days)
$52.11 • Monthly (per 30-day period)
RPM Clinical Review (First 20 Min)
$51.77 • Once per calendar month
RPM Initial Setup (One-Time)
$21.71 • One-time per episode of care
RPM Clinical Review (Additional 20 Min)
$41.42 • Monthly (per calendar month, add-on to 99457)
Complex CCM Initial 30 Minutes
$86.00 • Once per calendar month
PCM Physician Base (30 Min)
$88.00 • Once per calendar month
BHI Care Management (20 Min)
$53.00 • Once per calendar month
CoCM Initial Month (70 Min)
$163.00 • Once per CoCM episode — the initial month only (subsequent months bill 99493)
CoCM Subsequent Month (60 Min)
$130.00 • Monthly, in each month after the initial 99492 month
CoCM Add-On (Each 30 Min)
$66.00 • As needed, in 30-minute increments, in the same month as 99492 or 99493
Complex CCM Add-On (Each 30 Min)
$63.00 • Monthly, as needed, in addition to the base 99491
CCM Add-On (Each 20 Min)
$50.00 • Up to 2 units per calendar month, in addition to the base 99490
Subsequent AWV (Annual)
$138.00 • Annually — at least 11 full calendar months after the previous AWV
Sources & Compliance
HCPCS notice. HCPCS Level II codes and their descriptions are maintained by the Centers for Medicare & Medicaid Services (CMS). The plain-language descriptions, billing scenarios, and FAQs on this page are CCN Health’s editorial summary and are not the official CMS descriptors.
Reimbursement. Reimbursement figures shown are CCN Health estimates based on the CMS Medicare Physician Fee Schedule (CY 2026) using published RVU values and the 2026 conversion factor of $33.40. Final payment varies by locality (GPCI), facility status, and payer contract. Fee schedules, relative value units, and conversion factors are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use.
Sources. CMS Medicare Physician Fee Schedule, CY 2026 (cms.gov); CMS HCPCS Level II Code Set (cms.gov/hcpcs).
Disclaimer. This page is informational and does not constitute billing, clinical, or legal advice. Verify all codes, modifiers, and reimbursement amounts against your contracted payer agreements and the official CMS publications before billing.