AWV Billing: G0438 vs G0439, Required Elements and Eligibility for 2026

By Jay Chowdappa, MD, co-founder and CEO, Zynix AI · Updated October 30, 2026

Key takeaways

HCPCS G0438 bills a patient's first Medicare Annual Wellness Visit (AWV) and G0439 every later one, no more than once in a 12-month period. Both require a health risk assessment and a personalized prevention plan; the first visit establishes the history, provider list, measurements and screening schedule, and later visits update them. Patients pay nothing when the provider accepts assignment.

• The first AWV cannot take place within 12 months of Part B enrollment or of the Welcome to Medicare visit (IPPE, G0402).
• Required elements include the HRA, cognitive assessment, depression risk review, functional and safety review, a written screening schedule, opioid review and substance use screening.
• Advance care planning (99497) and the physical activity and nutrition assessment (G0136) are optional elements; billed with modifier 33 on the AWV claim, the patient's cost sharing is waived.
• A separate, medically necessary E/M visit on the same day can be billed with modifier 25, and the AWV can be furnished by telehealth.

What is the Medicare Annual Wellness Visit?

The AWV is a yearly Part B preventive visit to develop or update a personalized prevention plan and perform a health risk assessment. It is not a head-to-toe physical: Medicare does not cover routine physical exams, and patients pay the full cost of one. When the provider accepts assignment, the patient pays nothing for the AWV itself.

Medicare has three visit types that are easy to confuse:

A patient does not need to have had a Welcome to Medicare visit to qualify for an AWV. Claims for G0438 or G0439 within 12 months of a G0402 for the same patient are denied as exceeding the benefit maximum.

G0438 vs G0439: what each visit must include

The first AWV establishes the baseline and the subsequent AWV updates it. Both start with a health risk assessment the patient completes, which you or the patient can update before or during the visit.

What must the health risk assessment collect?

At a minimum, the HRA collects the patient's self-reported information on:

• Demographic data and a self-assessment of health status
• Psychosocial risks, such as depression, life satisfaction, stress, anger, loneliness or social isolation, pain and fatigue
• Behavioral risks, such as tobacco use, physical activity, nutrition and oral health, alcohol, sexual health, motor vehicle safety and home safety
• Activities of daily living (dressing, feeding, toileting, grooming, walking including balance and fall risk, bathing)
• Instrumental activities of daily living (phone use, food preparation, housekeeping, laundry, transportation, shopping, managing medications and finances)

CMS asks providers to consider how best to communicate with patients who speak other languages, have varying health literacy or have disabilities. For the functional review in the first AWV, CMS lists ability to perform daily activities, fall risk, hearing impairment, and home and community safety, including driving when appropriate.

Who can perform and bill an AWV?

Part B covers an AWV performed by a physician (MD or DO); a physician assistant, nurse practitioner or certified clinical nurse specialist; or a medical professional, such as a health educator, registered dietitian, nutrition professional or other licensed practitioner, or a team of them, directly supervised by a physician. Report a diagnosis code consistent with the visit; CMS does not require a specific one. FQHCs use G0468 for a visit that includes an IPPE or AWV.

Billing add-ons: E/M, advance care planning and G0136

Three add-on situations come up often, and each has its own cost-sharing rule.

• Same-day E/M visit. When a significant, separately identifiable, medically necessary problem is addressed, bill the E/M code (99202 to 99205 or 99211 to 99215) with modifier 25. Deductible and coinsurance apply to that part of the visit.
• Advance care planning (99497, 99498). Optional, at the patient's discretion. When it is delivered on the same day by the same provider and billed with modifier 33 on the AWV claim, Medicare waives the coinsurance and deductible, once per year. Outside the AWV, cost sharing applies.
• Physical activity and nutrition assessment (G0136). For 2026, CMS kept G0136 but rewrote it as a standardized, evidence-based assessment of physical activity and nutrition, 5 to 15 minutes, no more than once every 6 months; it previously described a social determinants of health risk assessment. As an optional AWV element billed with modifier 33 on the same claim, cost sharing is waived once per year.

CMS also pays for G0438 and G0439 when furnished by telehealth. If an AWV is denied for exceeding the once-per-year limit, any ACP or G0136 billed with it picks up the deductible and coinsurance.

Why the AWV matters to ACOs and practices

For value-based organizations the AWV is the most dependable yearly touchpoint with each patient. It sets the screening schedule, surfaces cognitive, depression, fall and substance use risks, and can serve as the initiating visit for chronic care management and for advanced primary care management when those services are discussed during it. Accurate problem lists from the visit also feed risk adjustment; see how the CMS-HCC V28 model treats diagnoses.

The hard part is reaching every eligible patient and getting them in the door prepared. Zynix AI's care plans for AWVs, TCM and CCM sequence outreach, booking, reminders and pre-visit tasks, and close only when each step is documented. Its appointment confirmations and no-show follow-up ask what is in the way, reschedule early and route exceptions to front-desk staff, while clinicians perform the visit and make every clinical decision.

This guide summarizes Medicare rules as CMS published them as of October 30, 2026. It is not legal or coding advice. CPT is a registered trademark of the American Medical Association. Check current CPT guidance, your Medicare Administrative Contractor (MAC) and each payer's policy before you change billing.

Frequently asked questions

What is the difference between G0438 and G0439?

G0438 is the first Annual Wellness Visit, billed once in a patient's lifetime; it establishes the health risk assessment, history, provider list, measurements, screening schedule and prevention plan. G0439 is every subsequent AWV, which reviews and updates those elements. Either can be billed only once in a 12-month period, and not within 12 months of an IPPE (G0402).

When is a patient eligible for their first Annual Wellness Visit?

A patient can have a first AWV once they have had Part B for more than 12 months and have not had a Welcome to Medicare visit (IPPE) or an AWV in the past 12 months. They do not need to have had an IPPE first. After that, Medicare covers one AWV every 12 months with no cost to the patient when the provider accepts assignment.

Can you bill an E/M visit on the same day as an AWV?

Yes, when a significant, separately identifiable and medically necessary problem is addressed. Bill the office E/M code with modifier 25 alongside the AWV. The patient's deductible and coinsurance apply to the E/M portion, so explain that before you address the new problem, since many patients expect the visit to be free.

Is advance care planning free when done during an AWV?

Yes, once per year. When advance care planning (99497, and 99498 if needed) is delivered on the same day by the same provider as the AWV and billed with modifier 33 on the AWV claim, Medicare waives the coinsurance and deductible. Outside the AWV, or if the AWV is denied for frequency, cost sharing applies.

Is the Annual Wellness Visit a physical exam?

No. The AWV is a planning visit built around a health risk assessment and a personalized prevention plan, with basic measurements such as weight and blood pressure. Medicare does not cover routine physical exams, so a routine exam without a specific illness, symptom or complaint is the patient's cost. Explain the difference when you book the visit.

Related reading

• How To Improve AWV Completion Rates With AI-Powered Outreach
• Annual Wellness Visits: How ACOs Can Build the First Layer of Scalable Care Capacity
• Pre-visit planning for value-based care: what to prepare

Source notes

CMS Medicare Learning Network (page last modified April 9, 2026): Annual Wellness Visit. https://www.cms.gov/medicare/coverage/preventive-services/medicare-wellness-visits/annual-wellness-visit

Medicare.gov: Yearly “Wellness” visits. https://www.medicare.gov/coverage/yearly-wellness-visits

Federal Register, 90 FR 49266 (November 5, 2025): CY 2026 Payment Policies Under the Physician Fee Schedule, final rule. https://www.federalregister.gov/documents/2025/11/05/2025-19787/medicare-and-medicaid-programs-cy-2026-payment-policies-under-the-physician-fee-schedule-and-other

About the author

Jay Chowdappa, MD is co-founder and CEO of Zynix AI. He is a physician, and ACOs led by him generated $300M+ in shared savings before he started Zynix AI to help care teams follow through on what their data already shows.