G0438
Description, Billing Rules, and Use Cases

HCPCS G0438 is used to bill a Medicare-covered Annual Wellness Visit (AWV) for patients in their first year of eligibility.

This service supports the development of a personalized prevention plan, risk assessment, and documentation of health history — separate from a routine physical exam.

What is HCPCS Code G0438?

G0438 represents the initial Annual Wellness Visit (AWV), a once-in-a-lifetime benefit for Medicare Part B beneficiaries. Unlike a traditional physical, this visit focuses on preventive care planning and risk factor identification, helping providers and patients collaborate on long-term health strategies.

Covered elements of the G0438 visit include:

Establishing a medical and family history

Recording vital signs (height, weight, BMI, blood pressure, etc.)

Screening for cognitive impairment and depression

Reviewing functional ability, safety risks, and fall history

Administering a Health Risk Assessment (HRA)

Creating a personalized prevention plan with recommended screenings, immunizations, and referrals

Documenting a list of current providers and medications

G0438 may only be billed once per lifetime per beneficiary and must be performed after the first 12 months of Medicare Part B enrollment.

G0438 Billing Requirements and Eligibility

To bill G0438, providers must follow strict Medicare guidelines related to timing, frequency, provider type, and documentation. This visit is designed to initiate a long-term preventive care strategy — not to duplicate a traditional physical exam or problem-oriented E/M service.

Patient Eligibility Criteria

The patient must be enrolled in Medicare Part B
G0438 can only be billed:
- Once per beneficiary per lifetime
- After the first 12 months of Medicare Part B enrollment (i.e., not during the first year of coverage)
Patients must not have received a Welcome to Medicare Visit (G0402) in the prior 12 months
A follow-up Annual Wellness Visit (G0439) may be billed no sooner than 12 months after G0438

Who May Deliver the Service

Physicians (MD/DO)
Non-physician practitioners, including:
- Nurse practitioners (NPs)
- Physician assistants (PAs)
- Clinical nurse specialists (CNS)
Providers must be:
- Enrolled in Medicare
- Authorized to furnish E/M services
- Practicing within their scope under state law

Supervising Provider and Setting

G0438 may be billed in the following care settings:

Physician office (POS 11)
Outpatient clinics
Federally Qualified Health Centers (FQHCs)*
Rural Health Clinics (RHCs)*
Telehealth setting (with modifier 95 and appropriate POS)*

*RHCs and FQHCs must follow specific billing rules and may receive payment via the All-Inclusive Rate (AIR) or PPS methodology, not the standard Medicare Physician Fee Schedule.

G0438 Billing Documentation Checklist

To bill G0438 compliantly, the following elements must be documented in the medical record for each beneficiary:

Confirmation of eligibility:
- Medicare Part B coverage verified
- No G0438 or G0402 visit billed in the prior 12 months
- This is the patient’s first Annual Wellness Visit (AWV)
Date of service and location:
- Place of service (e.g., office, telehealth) must be included
- If billed via telehealth, modifier 95 should be attached
Completed Health Risk Assessment (HRA):
- Self-reported questionnaire covering lifestyle, health status, and psychosocial risks
- Can be completed by patient or caregiver before or during visit
- Must be reviewed by provider during visit
Personal and family medical history:
- Documentation of significant illnesses, hospitalizations, and family disease history
List of current providers and suppliers:
- All active healthcare professionals and DME vendors involved in care
List of current medications:
- Include prescription, over-the-counter (OTC), supplements, and herbal remedies
Routine vital signs and measurements:
- Height, weight, BMI, and blood pressure
- Visual acuity (if assessed)
- Optional: pulse, respiration, or other indicators
Assessment of functional ability and safety:
- Activities of Daily Living (ADLs)
- Home safety risk review (e.g., fall risk, driving, environmental hazards)
Cognitive impairment screening:
- Structured review or screening tool for memory, confusion, or dementia risks
Depression risk assessment:
- Use of validated tool or structured discussion (e.g., PHQ-2, PHQ-9)
Written Personalized Prevention Plan (PPPS):
- Future screening schedule (e.g., mammogram, colonoscopy)
- Immunization needs (e.g., influenza, shingles, COVID)
- Referrals for wellness or community services if applicable

G0438 Time Thresholds and Code Combinations

HCPCS G0438 is billed for the initial Annual Wellness Visit (AWV) under Medicare Part B. It is time-insensitive (not time-based), but frequency-limited, meaning it can only be billed once per beneficiary per lifetime.

Use the following chart to determine the correct billing code:

Table showing frequency-based billing rules for G0438, including timing with G0402, transition to G0439, and telehealth use with modifier 95.

Key Reminders:

G0438 does not have a required time minimum, but CMS expects the visit to be comprehensive
It must occur at least 12 months after the start of Medicare Part B coverage
After G0438 is billed, future wellness visits should use G0439
G0438 and G0402 (Welcome to Medicare Visit) may not be billed within the same 12-month window

When to Use G0438:
Common Scenarios and Use Cases

G0438 should be billed for a Medicare patient’s first Annual Wellness Visit (AWV), which occurs after 12 months of Part B enrollment and has not previously been billed. It is used to establish preventive care goals and risk screenings, not to diagnose or manage acute conditions.

Here are examples of how G0438 is used in practice:

Newly Eligible Medicare Beneficiary (13 Months Post Enrollment)
A primary care physician:
- Reviews the patient’s personal and family history
- Performs a health risk assessment and fall screening
- Creates a screening schedule for colonoscopy and flu shots
- Documents cognitive and depression assessments
  Billing: G0438

Telehealth-Based Initial Wellness Visit
A nurse practitioner:
- Conducts a virtual G0438 via HIPAA-compliant telehealth platform
- Reviews medications and preventive needs
- Assesses mood and memory using validated tools
- Mails a written prevention plan after the visit
  Billing: G0438 + modifier 95

Patient Confused About “Physical” vs. “Wellness Visit”
A physician assistant:
- Explains the difference between routine physicals and Medicare-covered AWVs
- Focuses visit on screenings, immunization planning, and lifestyle risk factors
- Clarifies that no EKG, labs, or exam components are included unless clinically indicated
  Billing: G0438

Common G0438 Billing Mistakes
(and How to Avoid Them)

Because G0438 is a once-per-lifetime benefit, billing errors typically stem from timing issues, improper code substitution, or misunderstanding what qualifies as a covered Annual Wellness Visit.

❌ Billing G0438 Within the First 12 Months of Medicare Coverage
G0438 is only payable after the first 12 months of Part B enrollment. Use G0402 (“Welcome to Medicare” visit) for patients still within their first year.

❌ Repeat Billing of G0438 Instead of G0439
G0438 is lifetime-limited. Any subsequent AWVs must be billed using G0439. Check claims history or your EHR to avoid double-billing.

❌ Substituting a Physical Exam for an AWV
Medicare does not cover routine physicals. G0438 must focus on preventive planning and risk assessment — not a head-to-toe physical. If a medically necessary exam is performed, consider billing a separate E/M code with modifier -25, if appropriate.

❌ Missing Required Components (e.g., PPPS or HRA)
Failure to document the Health Risk Assessment (HRA) or Personalized Prevention Plan will likely result in denial. These are non-optional parts of the visit.

❌ Billing G0438 Without Proper Provider Type or Setting
Ensure the visit was performed by an eligible provider (e.g., MD, NP, PA) and billed from a compliant setting. If done via telehealth, modifier 95 must be used.

G0438 Description, Billing Rules, and Use Cases