G0438 CPT code: 2026 billing and frequency rules for the initial Annual Wellness Visit

G0438 is the HCPCS code Medicare uses to pay for a patient’s initial Annual Wellness Visit (AWV), the first visit that builds a personalized prevention plan. Medicare pays it once per lifetime, after the patient has had Part B for more than 12 months. The patient owes nothing when you accept assignment.

Search for the G0438 CPT code and you’ll find plenty of rate estimates but few timing rules. The three denial messages CMS wrote for G0438 all deal with visit history and dates, so timing is where you protect the claim.

We checked each rule below against CMS transmittals and 42 CFR 410.15 in September 2026, and the dollar figures come from CMS’s July 2026 fee schedule file.

HCPCS G0438 code facts at a glance

Is the G0438 CPT code a real CPT code?

G0438 is a HCPCS Level II code that CMS creates and maintains, so the AMA’s CPT manual doesn’t list it. Billers and fee sheets still call it CPT G0438 or CPT code G0438, and the label has no effect on payment.

HCPCS has two levels. Level I is the AMA’s CPT set of five-digit numeric codes. CMS runs Level II, an alphanumeric set of one letter plus four digits, as CMS’s HCPCS overview explains. HCPCS G0438 and the other Medicare AWV CPT codes go on the same CMS-1500 or 837P claim as your E/M codes.

The official HCPCS G0438 initial annual wellness visit descriptor reads: “Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit.” Sources don’t agree on the acronym. CMS’s AWV page and RAC topic 0028 print “PPS,” while the CGS fact sheet and RAC topic 0176 print “PPPS” and call it the “first visit.”

If your charge master lists the G0438 CPT code description with PPPS and a payer file shows PPS, you’re looking at the same service. Map both versions to one charge line. Then your team won’t hold a claim over an acronym.

Medicare has paid G0438 since January 1, 2011, the date the Affordable Care Act’s AWV benefit took effect. CMS Transmittal 2159 set up the claim edits and denial messages. Medicare still applies both to G0438 claims.

G0402 vs G0438 vs G0439: picking the right Medicare wellness code

Medicare’s three wellness codes follow the patient’s Part B timeline. G0402 covers the Welcome to Medicare visit in the first 12 months of Part B. After that window, the first Annual Wellness Visit is G0438, and each AWV after it is G0439.

These G codes for Medicare wellness take the place of the age-banded preventive codes. Original Medicare doesn’t cover 99381 to 99397, so a 99397 on a Medicare claim denies. Save those commercial preventive visit codes for commercial payers.

G0438 vs G0439: AWV history decides the code

The difference between G0438 and G0439 comes down to billing history. A patient with 10 years of Part B and no paid AWV still gets G0438, and any AWV after that first paid one is G0439.

The G0438 and G0439 descriptors differ by one word, initial versus subsequent, and the work differs with it. At the initial visit, the clinician builds the HRA baseline and records height and BMI. The G0439 CPT code description covers the later visits that update that baseline.

In 2026, G0438 pays $36.74 more than G0439 at the national non-QP rate ($174.35 vs $137.61). A first-ever AWV billed as G0439 can still pay at the lower rate, and that loss shows up only in your remits.

Can G0402 be billed with G0438?

No. Medicare won’t pay G0438 within 12 months of a paid G0402 for the same patient. That claim comes back with CARC 119 and RARC N130, and the patient’s notice (MSN 18.27) says the visit came too soon after the Initial Preventive Physical Exam.

Among the Welcome to Medicare codes, the G0402 CPT code description limits the visit to the first 12 months of Part B. Practices that bill it late in that year push the initial AWV back, since the G0438 window opens a year after the IPPE month.

A patient doesn’t need a G0402 to qualify for G0438. Under CMS’s AWV billing rules, a patient who skips the Welcome to Medicare visit becomes eligible for the initial AWV once the first 12 months of Part B end.

G0438 eligibility: coverage rules and the age limit myth

Medicare covers G0438 for a patient who is past the first 12 months of Part B and hasn’t had an IPPE or AWV paid in the last 12 months. The patient also can’t have a prior G0438 paid by any practice.

Coverage conditions from 42 CFR 410.15

1. Part B coverage has run longer than 12 months.
2. No IPPE or AWV was paid in the past 12 months.
3. No G0438 was paid before, at any practice.

Part A alone doesn’t qualify a patient, since the AWV is a Part B benefit. “Initial” means the patient’s first AWV ever, and for a patient who skipped wellness visits, that can come years after Part B starts. The full definitions behind G0438 Medicare coverage sit in 42 CFR 410.15.

Condition three is the one your EHR can’t see. A G0438 billed by another practice sits in Medicare’s claims history, outside your system, so the front desk needs the payer’s record before booking.

Does the G0438 CPT code have an age limit?

G0438 has no age limit. Eligibility runs on Part B tenure, so a 52-year-old on Medicare through disability qualifies on the same timeline as a 67-year-old.

The age myth comes from the commercial preventive codes, 99381 to 99397, which split patients into age bands. Medicare’s G codes don’t use age bands, and the regulation sets no upper cutoff. Check the Part B effective date on the eligibility response, since that date is the only clock Medicare uses.

Counting the 12 months between Medicare wellness visits

Medicare’s Common Working File counts 11 full months starting with the month after the last AWV, per CMS Transmittal 2575. For G0438 and G0439 timing, the patient becomes eligible again on the first day of the same calendar month one year later.

11 full months and 12 months describe the same rule

The regulation says 12 months, and the claims edit counts 11 full months after the service month. Add the service month back and you get 12 calendar months. Both phrasings describe one G0438 billing frequency rule, and CPT G0439 frequency follows the same count.

Medicare applies that count after a Welcome to Medicare visit too. CMS RAC topic 0077 says an AWV isn’t payable if an IPPE was paid within the previous 11 whole months. The first AWV opens on the first day of the IPPE month one year later.

Checking AWV history before you schedule G0438

A G0438 history check needs more than coverage dates. Medicare returns next eligible dates for preventive services through HETS and most MAC portals, as the HETS 270/271 companion guide lists.

1. Pull the Part B effective date from the 271 response.
2. Check the preventive next eligible dates in HETS or your MAC portal.
3. Ask the patient about wellness visits at other practices.
4. Record the next eligible date in your scheduling system.
5. Bill G0438 only if Medicare shows no prior G0438 payment.
6. Reschedule if an IPPE or AWV falls inside the window.

A visit booked one month early comes back as CARC 119 with N130, and an appeal has nothing to argue when Medicare’s dates are right. The patient needs a new visit on or after the eligible date, and our page on benefit maximum denials covers the remit side.

G0438 documentation requirements for the initial AWV note

Auditors accept a G0438 claim only when the note shows a completed health risk assessment and each initial AWV element in 42 CFR 410.15. That runs from cognitive screening to a written screening schedule for the next 5 to 10 years.

Seven items make up the core of the G0438 documentation requirements, and your template should prompt for each one before anyone signs the note:

• Completed health risk assessment
• Medical and family history, including medications and supplements
• Current providers and suppliers list
• Height, weight, BMI or waist circumference, and blood pressure
• Cognitive impairment detection and depression risk review
• Functional ability and safety review
• Written screening schedule and risk factor list, with personalized advice and referrals

The table below lists each element, with the two optional ones marked. Its last column shows where notes tend to fall short once a reviewer opens the chart.

Health risk assessment rules your template must meet

The HRA behind a G0438 claim collects self-reported answers and takes no more than 20 minutes to complete. That cap comes from 42 CFR 410.15, so write it into your template instructions.

The tool should also fit patients with limited English or health literacy needs. At minimum, the HRA covers demographics, self-assessed health, psychosocial and behavioral risks, and ADLs and IADLs. Patients can complete it before the visit or during it, and CGS Medicare’s AWV fact sheet lists the HRA criteria a MAC reviewer checks.

AWV documentation gaps auditors flag

CMS reported a 24.5% overpayment rate for AWVs in its 2024 improper payment data, a projected $307.5 million, on its CMS AWV compliance tips page. That rate covers G0438 and G0439 together.

Auditors reviewing a G0438 CPT code claim look for the method behind each finding. Name the tool and the score, such as Mini-Cog with a score of 4. Record that the patient got the written plan, and keep signatures and credentials legible, with any amendment labeled and dated.

Pull 10 recent AWV notes and score them against the table above. If more than a couple miss an element, an AWV documentation audit will show whether the gap sits in the template or in how clinicians use it.

G0438 performers and telehealth rules

A supervised clinical team can deliver G0438, and Medicare pays for the visit when it happens by video. Both rules change how you staff AWV days and which claims need a telehealth place of service.

Eligible performers and physician direct supervision

Medicare lets a physician, PA, NP, or clinical nurse specialist perform and bill G0438. A health educator, registered dietitian, nutrition professional, or other licensed practitioner can also perform it, but only under a physician’s direct supervision.

The regulation ties that supervision to a physician. An NP can perform and bill G0438 under their own NPI, but an NP can’t supervise an RN-led AWV. Plan AWV staffing around the physician’s schedule for that reason.

Under 42 CFR 410.32(b)(3)(ii), a physician can now provide direct supervision through real-time audio and video on a permanent basis. Audio-only doesn’t count, and the rule excludes services with a 010 or 090 global period. G0438 carries an XXX global, so it qualifies.

Telehealth rules for G0438 through December 31, 2027

Medicare pays G0438 when it’s furnished by telehealth, and patients can receive it at home without geographic limits through December 31, 2027, under the Consolidated Appropriations Act, 2026.

Use POS 10 when the patient is at home and POS 02 for any other location, per CMS’s telehealth FAQ updated February 26, 2026. Our POS 10 telehealth rules page covers the claim details.

The visit needs real-time audio and video. Record where the vitals came from, such as the patient’s home blood pressure cuff or a recent office reading. Hold any audio-only AWV until your MAC confirms it will pay.

Billing G0438 on the claim: diagnosis codes and modifiers

G0438 billing guidelines start with the patient’s AWV history, which decides between G0438 and G0439. After that, the claim needs a diagnosis code, and any same-day problem visit needs modifier 25 on the E/M line.

Professional claims go on the CMS-1500 or 837P with one unit. The G0438 CPT code needs no modifier when you bill it alone, and modifier 25 doesn’t belong on it. Keep the AWV on its own line even when an E/M follows on the same claim.

Diagnosis codes for a G0438 claim

A G0438 claim needs a diagnosis code, and CMS lets you choose any code consistent with the patient’s exam, per the CMS AWV page.

Z00.00, general adult exam without abnormal findings, is the common choice. Switch to Z00.01 if the visit turns up an abnormal finding. Chronic problems like I10 (hypertension) and E11.9 (type 2 diabetes without complications) go on the separate E/M line when you bill one. CMS doesn’t treat Z00.00 as a requirement.

Billing a same-day E/M with modifier 25

If a problem needs its own workup during the AWV, bill the office visit (99202 to 99205 or 99211 to 99215) with modifier 25 alongside G0438. The AWV stays free to the patient, and the E/M carries the normal Part B deductible and coinsurance.

Your note needs a separate E/M section, with the problem’s assessment and medical decision making written apart from the AWV work. A stable chronic condition that only gets a mention won’t support it. See our modifier 25 documentation rules for the note split and 99213 level selection for choosing the level.

Can G2211 be billed with G0438?

G2211 can go on a G0438 claim only as an add-on to a same-day office visit. Since January 1, 2025, CMS pays G2211 when an E/M billed with modifier 25 shares the day with an AWV, per CMS’s G2211 FAQ.

An AWV-only visit has no base code for G2211 to attach to. Published totals that add G2211 to the G0438 rate overstate what the AWV earns, since the add-on pays on the E/M line. Our G2211 add-on rules page has the full criteria.

Codes you can and can’t bill with G0438

Four services can pair with G0438 on the same day, beyond vaccines and covered screening labs. They are an office visit with its own documentation, G2211 on that visit, advance care planning (99497 and 99498), and the G0136 physical activity and nutrition assessment.

G0438 and G0439 both accept ACP with modifier 33 under the same waiver. You can bill 99497 and G0439 together on later wellness visits with the same setup.

CMS changed G0136 on January 1, 2026. The code now covers a physical activity and nutrition assessment of 5 to 15 minutes, in place of the social determinants of health (SDOH) assessment. Any reference that still calls G0136 an SDOH code is out of date. Name the tool you used, such as the Physical Activity Vital Sign or Mini-EAT.

G0444 needs a check before it goes on a G0438 claim. The initial AWV already includes a depression risk review, and Noridian’s AWV guidance says NCCI may bundle depression screening into an IPPE or initial AWV. Check the current quarter’s NCCI edits first, and our guide to NCCI edit denials covers what to do if one comes back.

G0438 reimbursement in 2026 and the math behind the rate

G0438 pays a national rate of $174.35 in 2026 for most practices, or $175.22 for clinicians in a qualifying Advanced APM, before your locality adjustment. The AWV carries no patient coinsurance, so Medicare pays 100% of the allowed amount.

Building the 2026 G0438 rate

CMS adds three relative value units for G0438 and multiplies the total by the conversion factor, using the figures in its July 2026 fee schedule file.

Your locality’s GPCI moves that amount up or down, and the 2% sequestration reduction comes off the paid amount. Nonphysician practitioners billing under their own NPI receive 85% of the fee schedule amount, which is $148.20 for G0438 at the non-QP rate.

G0439 totals 4.12 RVUs, which works out to $137.61 at the non-QP rate. That G0439 Medicare reimbursement figure is where the $36.74 gap between the two AWV codes comes from. The fee schedule lists the same totals for office and facility settings.

The two 2026 conversion factors

G0438 has two national rates in 2026 because Medicare uses two conversion factors for the first time: $33.5675 for qualifying APM participants and $33.4009 for all other clinicians. The CY 2026 PFS final rule fact sheet rounds them to $33.57 and $33.40.

Any single G0438 CPT code reimbursement figure misses part of the market. Confirm your clinicians’ factor and locality in the CMS PFS search tool before you model AWV revenue.

Medicare Advantage and FQHC payment (G0468)

Medicare Advantage plans can’t charge cost sharing for in-network Medicare-covered preventive services such as G0438, under 42 CFR 422.100(k). Your payment follows the plan contract, so payer contract analysis is how you find out whether a plan pays less than the fee schedule.

FQHCs bill G0468 with the G0438 service line. The G0468 CPT code description reads “Federally qualified health center (FQHC) visit, IPPE or AWV,” and it covers the typical bundle of services furnished that day. CMS raises the FQHC PPS payment by 34.16% when the visit includes an IPPE or AWV, per its FQHC PPS page.

G0438 denial codes and the fix for each

CMS set three denial messages for G0438 in Transmittal 2159. CARC 149 with RARC N117 flags a second G0438, and CARC 119 with N130 flags a visit too soon after an IPPE. A visit inside the first 12 months of Part B gets CARC 26 with N130.

Check the group code on each remit line. Even with PR, collect from the patient only if they signed a valid ABN (CMS-R-131) before the visit. Without that ABN, treat a denied G0438 CPT code claim as a practice loss and fix the step that caused it.

The E/M row is the one you can recover. A corrected claim needs modifier 25 and a note section that stands on its own, and our guide to CO-97 bundling denials covers that fix.

RAC audit topics that cover G0438

Recovery auditors review G0438 under three approved CMS topics. RAC topic 0028 targets more than one G0438 per lifetime, and RAC topic 0077 targets an AWV within 11 whole months of an IPPE.

Under CMS RAC topic 0176, approved August 28, 2025, auditors run complex reviews of G0402, G0438, and G0439 coding errors across all A/B MAC jurisdictions.

G0438 questions billing teams ask most

Does Medicare cover CPT G0438?

Yes. Medicare Part B covers CPT G0438 once per lifetime after the first 12 months of Part B, with no coinsurance or deductible when the provider accepts assignment.

Costs apply only to extra services, such as a same-day E/M or tests outside the preventive benefit. Front desk scripts for the G0438 CPT code should mention that problem care during the visit may carry the normal Part B deductible and coinsurance.

Can you bill G0438 after G0439?

No. G0438 applies to the patient’s first AWV, and a paid G0439 in the history means Medicare has already counted an AWV for that patient.

If your practice billed G0439 for what was the first visit, fix it with a corrected claim on the original date of service. RAC topic 0176 reviews this kind of mix-up across the three wellness codes.

Can a registered nurse perform the initial AWV?

A registered nurse counts as a licensed practitioner under the AWV rules, so an RN can perform G0438 under a physician’s direct supervision.

In 2026 that supervision can happen through real-time audio and video. Practices bill the visit under the supervising physician’s NPI in most cases, and an NP can’t take the physician’s place as supervisor for an RN-led AWV.

Can G0438 be billed with 99397?

Medicare excludes routine physicals by statute, so 99397 doesn’t pay on an Original Medicare claim. Bill G0438 for the AWV itself.

If the patient wants a full physical too, you can bill 99397 as non-covered with modifier GY. The patient pays for that service. Our page on age-banded preventive codes covers the commercial side, and the same logic applies if you’re asking whether you can bill G0439 and 99397 together.

Does G0438 require a physical exam?

No. G0438 calls for routine measurements, meaning height, weight, BMI or waist circumference, and blood pressure, with no hands-on exam.

Exam work for a new or active problem belongs on a separate E/M with modifier 25, and the note has to show it. Plenty of patients expect a head-to-toe physical, so explain the difference when you book.

Does an AWV at another practice count toward the limit?

Medicare tracks AWV limits per beneficiary, so a G0438 paid to another practice counts against the patient’s lifetime limit and starts the 11-month clock.

Your own records won’t show that visit. Check HETS or your MAC portal for the next eligible date before booking, and bill G0439 if another practice already used the G0438. Ask new patients about recent wellness visits at intake as a backup.

G0438 pre-submission checklist

Run these seven checks before any G0438 claim goes out. They follow the G0438 billing guidelines above in the order the claim meets them.

1. Part B started more than 12 months ago.
2. No IPPE or AWV was paid in the last 11 whole months.
3. No G0438 was ever paid at any practice; if one was, the visit bills as G0439.
4. The HRA is complete, and each initial AWV element is in the note.
5. A diagnosis code is on the claim, with problem diagnoses on the E/M line.
6. Modifier 25 sits on any same-day E/M, modifier 33 on ACP or G0136, and G2211 on the E/M only.
7. The setting matches the claim: POS 10 or 02 for telehealth, G0468 with G0438 at an FQHC.

Print this list or save it as a G0438 CPT code PDF checklist for the front desk. Recheck it each quarter when CMS posts fee schedule updates, and follow MAC billing updates between those dates.

Sources

• CMS Transmittal 2159 (AWV claim edits and denial messages)
• CMS Transmittal 2575 (AWV frequency count)
• CMS RAC topic 0028: Annual Wellness Visits
• CMS RAC topic 0077: Annual Wellness Visit
• CMS RAC topic 0176: AWV incorrect coding
• 42 CFR 410.15 (eCFR)
• 42 CFR 410.32 (eCFR)
• 42 CFR 422.100 (eCFR)
• CMS Annual Wellness Visit page
• CMS Initial Preventive Physical Exam page
• Medicare.gov: Yearly wellness visits
• CMS Telehealth FAQ, updated February 26, 2026
• HHS telehealth policy updates
• CMS HCPCS G2211 FAQ
• CY 2026 PFS final rule fact sheet
• MLN Matters MM14315: CY 2026 PFS final rule summary
• CMS PFS indicator data, 2026
• CMS PFS search tool
• CMS FQHC PPS page
• MLN evaluation and management services guide
• HETS 270/271 companion guide v13.0
• CGS Medicare AWV fact sheet
• Noridian JE Part B: IPPE and AWV
• CMS compliance tips: Annual Wellness Visits
• AAFP: Annual wellness visit coding