Medicare Wellness Exam Billing Guidelines

Correct Coding Practices

The American Medical Association recommends using Medicare-specific G-codes, such as G0438 for initial visits and G0439 for subsequent visits, instead of standard preventive care codes for Medicare wellness exams 1
Medicare does not reimburse standard preventive care codes (99381-99397) for wellness visits, and instead requires the use of G0438 and G0439 codes 1

Medicare Annual Wellness Visits (AWVs) focus on health risk assessment, personalized prevention planning, and screening for cognitive impairment, rather than comprehensive physical examinations, as recommended by the Centers for Medicare and Medicaid Services 2

The American Academy of Family Physicians suggests using modifier 25 on the wellness visit code when billing a separate evaluation and management service on the same day 1
Developmental or cognitive screening (CPT 96110) can be added to the wellness visit with an appropriate modifier, according to the American Medical Association 1
If the visit becomes complex and requires significant problem-focused evaluation beyond the wellness visit scope, an appropriate E/M code (99212-99215) may be billed in addition to the wellness visit code with modifier 25, as recommended by the American College of Physicians 3, 1

The American Academy of Family Physicians confirms that 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, as supported by Circulation in 2018 4
For patients with Medicare supplemental insurance, the supplemental plan typically covers any copayments or deductibles that Medicare Part B doesn't cover for the AWV, according to the American Academy of Family Physicians in 2001 5

Documentation must clearly distinguish between the wellness visit components and any additional problem-focused care to justify billing both codes, with the time spent documented if billing based on time for any additional E/M services, as supported by Circulation in 2018 4