Annual Wellness Visit (AWV)

HCPCS/CPT Codes

Frequency

  • G0438 - Once in a lifetime
  • G0439 and G0136 - Annually

Coverage

  • Beneficiary not within 12 months after effective date of their first Medicare Part B coverage period
  • Has not received Initial Preventive Physical Examination (IPPE) or AWV within past 12 months
  • Performed by health professional:
    • Physician
    • Physician assistant
    • Nurse practitioner
    • Clinical nurse specialist
    • Medical professional (including health educator, registered dietitian, nutrition professional or other licensed practitioner) or team of such medical professionals, working under direct supervision of physician

No specific diagnosis code required; bill using the most appropriate diagnosis

Payment

  • AWV copayment and deductible waived
  • G0136 copayment and deductible waived when:
    • Provided same day, by same provider, same claim as covered AWV
    • Billed with modifier 33 (Preventive Service)

Noridian Medicare Portal

Yes - G0438 and G0439

Billing Social Determinants of Health (SDoH) Risk Assessment

  • Implementation for SDOH Risk Assessment claims is January 1, 2024
  • CMS waives both coinsurance and deductible when it's:
    • Provided on same day as covered AWV
    • Provided by same provider as covered AWV
    • Billed with modifier 33 (Preventive Service)
    • Billed on same claim as AWV
  • Deductible and coinsurance applied when provided outside covered AWV

If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when the SDOH Risk Assessment is delivered outside the covered AWV.

Resources

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