Over a decade ago, The Affordable Care Act extended coverage of preventive services under the Medicare program, specifically personalized prevention plan services (PPPS) beginning January 1, 2011. [1] Now well known as the Annual Wellness Visit (AWV), this service continues to cause significant confusion among health systems, and particularly, the practitioners responsible for rendering it.
Billed with either HCPCS G0438 for the initial visit, or G0439 for the annual subsequent visit, recent Targeted Probe and Education (TPE) initiatives by Medicare Administrative Contractors (MACs), highlight the importance of ensuring documentation and other deficiencies in workflow are remedied. Significantly, in CY 2024, the U.S. Department of Health & Human Services (HHS) identified an improper payment rate of 24.5% for the subsequent AWV, HCPCS Code G0439. [2] Denial reasons cited by MACs include insufficient documentation, medical necessity not supported, performing provider wasn’t the billing provider, and AWV billed too soon as these visits can only be billed once in a 12-month period.
Below, we provide an overview of this preventative encounter including important considerations and recommendations for maintaining compliance with documentation, coding, and billing of these services.
Overview
The AWV is a person-centered visit in which a personalized prevention plan is developed after a shared decision-making process between patient and physician or advanced practice practitioner (APP). With the goal of early detection, interventions, and closing care gaps, the AWV is designed to mitigate disease, reduce risk and improve health outcomes; [3] objectives that should be reflected in the provider’s assessment and resulting prevention plan.
Often confused with an annual physical examination, which historically has not been covered by the Medicare program, the AWV does include some required examination components, such as vitals, height, weight, BMI (or waist circumference), and blood pressure. However, a comprehensive physical exam is not required.
Rather, this encounter is an opportunity for practitioners to step back from that traditional process, gleaning insights into the patient’s ability to function safely in their home environment and everyday life, ensuring all care needs, both physical and behavioral, are met. To facilitate this, in addition to establishing or reviewing the patient's medical and family history, vitals, and biometric information, the AWV embodies the following core components: [4]
Perform, review, or update the patient Health Risk Assessment (HRA)
Establishing a current provider/supplier list
Detecting cognitive impairments
Evaluating risk factors for depression
Reviewing functional ability and level of safety in everyday activities
Reconciling medications including any opioid prescriptions and screening for any potential substance use disorders
Establishing an appropriate written screening schedule based on United States Preventive Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP) recommendations
Identifying the patient’s list of risk factors and current conditions
Providing personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs
Providing Advance Care Planning (ACP) Services at patient’s discretion; separately billed
New for 2026: Conduct Physical and Nutrition Assessment; optional and separately billed [5]
HRA
A cornerstone of the AWV is the mandatory HRA, which is an established tool used to identify risk factors associated with acute and chronic conditions. The HRA is completed during the initial AWV and should be reviewed and updated at all subsequent AWV encounters. The information gathered through the HRA should be synthesized by the physician or APP to inform the development or refinement of a prevention plan.
To support identification of care gaps and patient risk factors, CMS outlines specific activities and behaviors that should be assessed as part of the HRA. Providers should ensure that both the HRA and supporting documentation templates capture these elements accurately. For reference, “A Framework for Patient-Centered Health Risk Assessments”, developed by the Centers for Disease Control and Prevention, includes a sample HRA (see page 43): View CDC HRA Framework.
Rendering Practitioner
Often misunderstood, the AWV cannot be rendered under Medicare’s incident-to framework as CMS does not permit any service having its own benefit category to be rendered as an incident-to service. Therefore, the practitioner who renders the service must also bill, which is highlighted by CGS Medicare in their TPE initiative. Among the top denial reasons identified was incongruity between the rendering and billing provider. [6]
The personal involvement of the billing practitioner is not only underscored in its valuation and time expectation for the AWV as put forth under the Medicare Physician Fee Schedule (MPFS), but in October 2025 this was validated during a provider symposium co-hosted by MAC’s First Coast Service Options and Novitas Solutions.
Engendering confusion amongst providers, CMS does allow some latitude in the provision of the overall service per their Frequently Asked Questions surrounding the AWV:
“As discussed in the preamble of the calendar year 2011 Physician Fee Schedule rule, CMS is not assigning particular tasks or restrictions for specific members of the team. We believe it is better for the supervising physician to assign specific tasks to qualified team members (as long as they are licensed in the State and working within their state scope of practice). This approach gives the physician and the team the flexibility needed to address the beneficiary’s particular needs on a particular day. It also empowers the physician to determine whether specific medical professionals who will be working on his or her wellness team are needed on a particular day. The physician is able to determine the coordination of various team members during the AWV.” [7]
While Medicare allows the supervising physician to determine which tasks may be delegated to qualified team members, this flexibility is intended to support a team-based approach similar to evaluation and management services, where clinical staff collect and document history and vitals for physician review. Specific to the AWV, while clinical staff may assist patients complete the HRA and perform various screenings and assessments within their designated practice scope, this does not preclude the role of the physician or APP in rendering the overall service.
Given the error rate identified by HHS and the increase in TPE initiatives, SunStone encourages physician practices and health systems to examine workflows and validate that all required visit components are documented for both the initial and subsequent AWV and the billing practitioner is involved in rendering the service.
SunStone Consulting offers comprehensive services geared to help hospitals and health systems evaluate and navigate the ever-changing regulatory environment. If you have any questions, please contact Vonda Moon, Senior Principal at vondamoon@sunstoneconsulting.com, Joli Fitzgibbons, Senior Director at jolifitzgibbons@sunstoneconsulting.com or Cathy Archuleta, Senior Manager at cathyarchuleta@sunstoneconsulting.com.
[1] https://www.govinfo.gov/content/pkg/FR-2010-08-03/pdf/2010-16448.pdf
[2] https://www.cms.gov/files/document/2024-medicare-fee-service-supplemental-improper-payment-data.pdf
[3] https://stacks.cdc.gov/view/cdc/23365
[4] https://www.cms.gov/medicare/coverage/preventive-services/medicare-wellness-visits/annual-wellness-visit
[5] 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
[6] https://www.cgsmedicare.com/partb/mr/pmr.html
[7] https://www.cms.gov/outreach-and-education/outreach/npc/downloads/ippe-awv-faqs.pdf