Annual Wellness Visit Checklist: From Intake to a Clean Claim

This annual wellness visit checklist follows one Medicare patient from the eligibility check to a signed note and a claim that goes out clean. The Annual Wellness Visit (AWV) is a prevention planning visit, and the payer expects specific elements to be done and written down. Work through the lists below in order, and confirm each rule against the current CMS guidance, because the details change from year to year.

What the Annual Wellness Visit is, and what it is not

The AWV is a Medicare Part B preventive benefit. Its purpose is to build and then update a personalized prevention plan: what the patient is at risk of, what screenings are due, and what advice and referrals follow from that.

It is not a head-to-toe physical exam. A patient who books "my yearly physical" may expect one, and the AWV does not cover it. Saying this plainly when the visit is booked saves a confused conversation at check-out.

There are two codes:

The Initial Preventive Physical Examination (IPPE), often called the "Welcome to Medicare" visit, is a different service with its own code and its own timing. Do not bill one as the other.

Before the visit: confirm the patient is eligible

The first checks happen before anyone sees the patient. In general, CMS describes a beneficiary as eligible when:

• the patient has had Medicare Part B for more than 12 months
• the patient has not had an IPPE or an AWV in the past 12 months
• for G0438, the patient has never had an initial AWV, with your practice or anywhere else

Check how CMS counts the 12 months in its current wording, and check the patient's coverage rather than relying on memory. A patient on a Medicare Advantage plan is covered under that plan's rules, which can differ. Our insurance eligibility verification checklist covers the coverage check itself.

Front desk checklist:

• Coverage confirmed on file, with the date it was checked
• Last AWV or IPPE date asked for and noted, including visits at other practices
• Patient told what the visit is (prevention planning, not a physical)
• Patient told that a separate problem-focused service on the same day may carry its own cost sharing

Before the visit: collect what the patient can fill in

The health risk assessment (HRA) is the backbone of the AWV. A patient can complete it before the visit, in the waiting room, or with staff. CMS sets minimum topics for the HRA, which in its current guidance include demographic data, a self-assessment of health status, psychosocial and behavioral risks, and activities of daily living, including instrumental ones such as managing money or medications. Check the current list before you design your form.

• HRA sent or handed to the patient, in a form they can read
• HRA completed and reviewed before the clinician walks in
• Medical and family history updated
• Current medications and supplements listed
• List of the patient's current providers and suppliers updated

During the visit: the elements to complete and document

The initial and subsequent visits share most elements, but not all. This table is a general summary; the current CMS list is the source of truth.

Clinician checklist:

• Each required element done and written in the note, not only discussed
• Cognitive assessment method named (direct observation, a structured tool, or input from family)
• Screening schedule given to the patient in writing
• Risk factors listed with the intervention or referral for each
• Advance care planning, if done, recorded with the patient's agreement and how long it took
• Any optional assessment, if done, recorded on its own

Who may furnish the AWV is set by CMS and by your state's scope of practice rules. CMS allows certain health professionals working under a physician's direct supervision, so confirm who on your team qualifies before you build the workflow around them.

After the visit: coding, signing and sending the claim

A complete visit can still produce a claim that comes back. These are the checks that catch it.

• Correct code chosen: G0438 only if no initial AWV was ever furnished, G0439 otherwise
• Date of service is the day the visit happened
• Diagnosis codes are billable, specific codes, not category codes that need a subcode
• If a separate problem-oriented service was also furnished, it is documented on its own and coded under your payer's rules for same-day services
• Provider has reviewed and signed the note
• Any correction to diagnoses is made before the claim is sent, not after

On the same-day question: CMS generally allows a significant, separately identifiable problem-oriented visit on the same day as the AWV, typically reported with a modifier. Whether it is billable, and what the patient owes for it, depends on the documentation and the payer. Ask your billing adviser before it becomes a habit.

For the claim side in more depth, see how to reduce claim denials.

Reasons an AWV claim comes back

Use this list to review rejected or denied AWV claims at your next billing meeting.

• The visit was billed too soon after the last AWV or IPPE
• G0438 was billed for a patient who already had an initial AWV somewhere
• The patient was still in their first 12 months of Part B, when the IPPE applies
• A required element was missing from the documentation
• A diagnosis code was not billable as entered
• The note was not signed when the claim went out

Each of these is a front desk or documentation fix, not a payer dispute. Track which one hit and fix the step that let it through.

Bringing eligible patients in

An AWV only helps the patient, and the practice, if it happens. A practice that tracks who is due can reach those patients by phone, text or letter, and record who was reached. Our guide on how to run a patient outreach campaign walks through building that list and working it, with consent and calling hours checked first.

Frequently asked questions

Is the Annual Wellness Visit the same as an annual physical?

No. The AWV is a prevention planning visit built around a health risk assessment, a screening schedule and personalized advice. It does not include a head-to-toe physical exam. Tell patients this when the visit is booked.

What is the difference between G0438 and G0439?

G0438 is the initial AWV, furnished once. G0439 is every subsequent AWV after the interval has passed. Billing G0438 for a patient who already had an initial AWV, even at another practice, sends the claim back.

Can we bill a problem visit on the same day as the AWV?

CMS generally allows a significant, separately identifiable problem-oriented service on the same day, documented on its own and reported with a modifier. Payer rules and patient cost sharing vary, so confirm with your billing adviser and your payer contracts.

Does the patient have to complete the health risk assessment before the visit?

No. It can be completed before or during the visit, by the patient or with help from staff. Completing it beforehand gives the clinician time to review it and keeps the visit focused.

Is advance care planning required at the AWV?

No. It is optional and done only with the patient's consent. If it is furnished, record the discussion and the time spent, and check the current CMS rules for how it is billed alongside the AWV.

Sources

• Annual Wellness Visit, CMS
• 42 CFR 410.15, Annual wellness visits providing personalized prevention plan services, Code of Federal Regulations
• Medicare and Medicaid Programs; CY 2026 Payment Policies Under the Physician Fee Schedule (final rule), Federal Register