What's required in an initial AWV (G0438)?

Minimum elements for an initial AWV (G0438) include: 1) Health Risk Assessment (HRA) covering demographics, self-rated health, psychosocial risks, behavioral risks, ADLs/IADLs, 2) Updated medical and family history, 3) Current providers/suppliers list, 4) Measurements (height, weight, BMI, blood pressure), 5) Cognitive impairment assessment and depression risk review, 6) Functional ability and safety assessment (ADLs, fall risk, hearing, home/community safety), 7) Written screening schedule (5-10 years), 8) List of risk factors/conditions with interventions and treatment options, 9) Personalized health advice and referrals (fall prevention, nutrition, physical activity, tobacco cessation, etc.). These are the core CMS requirements that must be documented to support G0438 billing.

What changes for a subsequent AWV (G0439)?

The subsequent AWV (G0439) focuses on reviewing and updating key elements from the initial AWV: 1) Update the HRA using the same minimum categories, 2) Update medical/family history and current providers list, 3) Update measurements (weight/waist and blood pressure), 4) Repeat cognitive impairment check, 5) Update the written screening schedule based on current risk profile, 6) Update risk factors/conditions list and intervention recommendations, 7) Update personalized prevention plan/referrals. The subsequent AWV emphasizes continuity and tracking changes over time rather than starting from scratch.

Can we bill an E/M visit with an AWV on the same date?

Yes—when a significant, separately identifiable, medically necessary problem-oriented E/M service is performed and documented distinctly from the AWV components. CMS indicates that the E/M service may be reported with modifier 25, and that portion must be medically necessary and reasonable. Best practice: clearly separate AWV prevention-plan work (HRA, screening schedule, risk factors, counseling/referrals) from problem-oriented assessment/plan (complaint evaluation, MDM, orders, treatment changes) in your documentation. Simply adding a problem to the AWV documentation is not sufficient—the problem-oriented work must be substantial enough to warrant a separate E/M service.

Which codes are used for AWVs?

G0438 is used for an initial Annual Wellness Visit (first AWV) and G0439 is used for a subsequent Annual Wellness Visit (annual follow-ups). CMS also notes that AWVs can be furnished via telehealth when other requirements are met. Do not confuse AWV codes with IPPE (Initial Preventive Physical Examination, code G0402), which is the 'Welcome to Medicare' visit available only within the first 12 months of Medicare Part B enrollment.

Who can perform an AWV?

CMS describes AWVs as payable when performed by a physician or qualified non-physician practitioner (such as nurse practitioners and physician assistants). CMS also notes team-based performance under appropriate supervision, meaning clinical staff (such as medical assistants or registered nurses) can capture structured HRA data, functional/safety screens, and measurements under the supervision of the qualified provider who completes the cognition review, prevention plan, screening schedule, risk factors, and referrals. Always verify your state's scope of practice laws and Medicare billing rules for your specific provider types.

What are the most common AWV denial triggers?

The most frequent AWV denial triggers are: 1) Eligibility not verified—patient not eligible due to Part B timing or recent IPPE/AWV within past 12 months, 2) AWV performed by ineligible provider or without appropriate supervision, 3) Missing core AWV documentation elements—documentation lacks required HRA, prevention plan, or screening schedule, 4) Incomplete Health Risk Assessment—HRA missing minimum required categories (demographics, psychosocial, behavioral, ADLs), 5) Missing written prevention plan artifacts—no written screening schedule or personalized prevention plan provided to patient, 6) Improper same-day E/M billing—E/M billed with AWV without clear separation or modifier 25. To prevent denials: verify eligibility before the visit, use structured templates ensuring all CMS-required elements are captured, document problem-oriented E/M work separately with modifier 25 when applicable.

How can ChartWhisper help with AWV documentation?

ChartWhisper can help teams standardize AWV documentation by: 1) Auditing for missing required AWV components (HRA elements, screening schedule, personalized prevention plan artifacts), 2) Flagging workflow gaps that commonly trigger denials (eligibility/frequency checks, incomplete prevention plan), 3) Supporting coders/compliance with consistent, repeatable QA across AWV volumes, 4) Identifying opportunities for same-day E/M billing when problem-oriented work is documented, 5) Providing provider feedback loops to improve AWV documentation quality and completeness. Important Notice: ChartWhisper is an AI-powered documentation assistant; outputs are suggestions for review and verification and do not guarantee coding accuracy. Final documentation and billing decisions remain the provider's responsibility. Book a demo to walk through Medicare preventive service workflows using your real encounter patterns.

Medicare Preventive Services Compliance

AWV Documentation Guide

Everything You Need for a Medicare-Compliant Annual Wellness Visit

A practical checklist and workflow for documenting initial and subsequent AWVs (G0438/G0439), including HRA, prevention plan, screening schedule, and billing guardrails.

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This guide is designed for:

Provider Groups

Documentation consistency + point-of-care support

Coders & Compliance

Defensible abstraction + audit-ready evidence

Health Plans/MAOs

Prospective/retrospective review + quality assurance

Practice Managers

Workflow optimization + denial prevention

Overview: What an AWV Is (and Isn't)

A Medicare Annual Wellness Visit (AWV) is a preventive visit to develop or update a personalized prevention plan and complete a Health Risk Assessment (HRA)—it's not the same as a routine physical exam. Medicare covers the AWV once every 12 months, while routine physical exams are generally not covered as a standalone benefit.

Use this guide to:

Document the required AWV elements (initial + subsequent)
Reduce denials by confirming eligibility/frequency
Build a repeatable workflow across front desk → MA/clinical staff → provider → coding/compliance

AWV Eligibility & Frequency (Denial-Proof Basics)

Medicare Coverage Requirements

Medicare covers an AWV when the patient:

Is not within the first 12 months after their Medicare Part B effective date, and
Hasn't had an IPPE ("Welcome to Medicare") or an AWV within the past 12 months

Frequency rule (operationally):

AWV is covered annually (CMS describes it as covered once every 12 months / 12 months after the last AWV or IPPE).

Pro tip for teams:

Always verify eligibility before the visit (especially if the patient had an AWV at another practice).

AWV Codes (What You're Actually Billing)

G0438

Initial AWV

First Annual Wellness Visit for a patient who has not received an AWV within the past 12 months

G0439

Subsequent AWV

Annual follow-up AWV for patients who have had an initial AWV or previous subsequent AWV

Note: CMS also notes AWVs can be furnished via telehealth (when other requirements are met).

Initial AWV (G0438): Required Documentation Checklist

Below are the core elements CMS lists for the first AWV. Treat this as your minimum documentation floor.

Health Risk Assessment (HRA) — Minimum Data Capture

Document that the HRA was completed and include, at minimum:

Demographics + self-rated health
Psychosocial risks (e.g., depression, stress, loneliness, pain, fatigue)
Behavioral risks (tobacco, activity, nutrition/oral health, alcohol, sexual health, safety)
ADLs and IADLs (functional status, fall/balance risk, medication management, finances, etc.)

Medical + Family History (Updateable Each Year)

Include:

Relevant family medical events (parents/siblings/children; hereditary risk)
Past medical/surgical history, hospitalizations, allergies, injuries, treatments
Medications/supplements/substance exposure

Current Providers/Suppliers List

Document a current list of providers/suppliers involved in care (including behavioral health).

Measurements

Record:

Height, weight, BMI (or waist circumference if appropriate), blood pressure
Other routine measurements as appropriate

Cognitive + Mood Risk Review

Cognitive impairment assessment (observation and/or patient/caregiver reports)
Depression risk factor review (using a recognized tool where appropriate)

Functional Ability + Safety (Minimum Domains)

At minimum address:

ADLs, fall risk, hearing impairment
Home/community safety (including driving when appropriate)

Written Screening Schedule (5–10 Years)

Provide a written screening schedule based on patient history/risk and evidence-based recommendations.

Risk Factors/Conditions List + Interventions

Include:

Identified risk factors/conditions (including mental health, SUD, cognitive concerns)
Recommendations for interventions (primary/secondary/tertiary) or note what's underway
Treatment options with risks/benefits

Personalized Health Advice + Referrals

Document tailored health advice and referrals (examples CMS lists include fall prevention, nutrition, physical activity, tobacco cessation, social engagement, weight loss, cognition).

Optional Elements (Document Only When Performed)

Advance Care Planning (ACP): may be provided at patient discretion during AWV.
Opioid review / SUD screening / SDOH risk assessment: CMS describes these as part of AWV content (SDOH risk assessment is described as optional).

Subsequent AWV (G0439): What Must Be Updated

For subsequent AWVs, CMS emphasizes review and update of key items:

Update HRA

Same minimum categories as initial AWV

Update Medical/Family History

Plus current providers list

Measure Weight/Waist & BP

If appropriate for patient

Repeat Cognitive Check

Cognitive impairment assessment

Update Screening Schedule

Written schedule based on current risk

Update Risk Factors

Conditions + interventions

Update Prevention Plan/Referrals

Personalized prevention plan and appropriate referrals based on current status

Note: ACP remains at patient discretion (if performed, document)

Billing Guardrails: AWV + Problem-Oriented E/M on the Same Day

If you perform a significant, separately identifiable, medically necessary problem-oriented E/M service during the same encounter, CMS indicates you may bill the additional E/M code with modifier 25, and that portion must be medically necessary and reasonable.

Documentation best practice: clearly separate

AWV prevention-plan work: HRA, screening schedule, risk factors, counseling/referrals
Problem-oriented assessment/plan: Complaint evaluation, MDM, orders, treatment changes

Important:

Simply adding a problem to the AWV documentation is not sufficient—the problem-oriented work must be substantial enough to warrant a separate E/M service and must be documented distinctly from the AWV prevention elements.

Common AWV Denial Triggers (and How to Fix Them)

CMS's compliance guidance emphasizes preventing denials by ensuring:

Eligibility not verified

Problem: Patient not eligible due to Part B timing or recent IPPE/AWV.

Fix: Verify eligibility before visit (last AWV/IPPE date, payer rules)

AWV performed by ineligible provider

Problem: AWV not performed by physician or qualified non-physician practitioner.

Fix: Ensure AWV is performed by eligible provider under appropriate supervision

Missing core AWV documentation elements

Problem: Documentation lacks required HRA, prevention plan, or screening schedule.

Fix: Use structured template ensuring all CMS-required elements are captured

Incomplete Health Risk Assessment

Problem: HRA missing minimum required categories (demographics, psychosocial, behavioral, ADLs).

Fix: Implement comprehensive HRA questionnaire covering all CMS categories

Missing written prevention plan artifacts

Problem: No written screening schedule or personalized prevention plan provided to patient.

Fix: Generate and document written prevention plan with screening schedule

Improper same-day E/M billing

Problem: E/M billed with AWV without clear separation or modifier 25.

Fix: Document problem-oriented E/M work separately from AWV prevention elements with modifier 25

Operational Workflow

Provider Groups + Coders + Compliance + Plans

1Pre-Visit (Front Desk / Scheduling)

Verify eligibility (last AWV/IPPE date; payer rules)
Send HRA questionnaire in advance (patient portal/text/email)

2In-Visit (MA/Clinical Staff + Provider)

Staff can capture structured HRA, functional/safety screens, measurements
Provider completes cognition review, prevention plan, screening schedule, risk factors, referrals

3Post-Visit (Coding/Compliance)

Confirm G0438 vs G0439 selection
Confirm written prevention plan artifacts are present (screening schedule + risk factors + interventions)
If E/M billed same day: confirm distinct documentation and modifier 25 support

How ChartWhisper Helps (Without Replacing Compliance Judgment)

ChartWhisper can help teams standardize AWV documentation by:

Auditing for missing required AWV components (HRA elements, screening schedule, PPPS artifacts)

Flagging workflow gaps that commonly trigger denials (eligibility/frequency checks, incomplete prevention plan)

Supporting coders/compliance with consistent, repeatable QA across AWV volumes

Identifying opportunities for same-day E/M billing when problem-oriented work is documented

Important Notice: ChartWhisper is an AI-powered documentation assistant; outputs are suggestions for review and verification and do not guarantee coding accuracy. Final documentation and billing decisions remain the provider's responsibility.

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AWV Documentation FAQ

Answers to common questions about Medicare Annual Wellness Visit documentation and billing

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See how ChartWhisper helps provider groups, coders, compliance teams, and health plans ensure Medicare-compliant AWV documentation.