Medicare Wellness Codes

Medicare Wellness Codes

Medicare Wellness Codes

Are you confused about the “Welcome to Medicare” and the Medicare Annual Wellness codes? You are not alone.Here is a succinct primer.

What are these new codes for?

The purpose of these codes is to provide a Personalized Preventative Plan at no cost to the patient- much like commercial insurers do- for Medicare beneficiaries. These codes are different from the commercial insurer’s annual preventative codes because Medicare has different documentation requirements than the commercial insurers. Working with your patient to develop and update a personalized prevention plan provides an ongoing focus on prevention that adapts as a patient’s health needs change over time.

When do I use these codes?

  • G0402 is the “Welcome to Medicare” code
  • Can only be used within the first twelve months of a Medicare beneficiary’s coverage. (i.e. within 12 months of the date their Medicare coverage became effective). This is a ‘once in a lifetime’ code…can only be used 1 time for a given Medicare patient.
  • G0438 is the “Annual Wellness Visit” code
  • Use this code for the first annual wellness visit 12 months following the Welcome to Medicare visit, or, if this is their first wellness visit and it is occurring beyond the first 12 months of their Medicare coverage. Do not use this code during the first twelve months of Medicare coverage (use G0402 instead). This is also a ‘once in a lifetime’ code….can only be used 1 time.
  • G0439 is the “Annual Wellness Subsequent Visit” code
  • Use this code for annual wellness visits at least 12 months following G0438. Can be used every 12 months.

What documentation do I need to provide to bill these codes?

For each of these codes, your documentation must include the following completed forms:

  • Preventive Services Schedule
  • Patient Health Risk Assessment Questionnaire
  • Medicare Wellness Visit form

These forms are available at OurNet/Administrative/Center for the Advancement of Primary Care (link is on the right-hand side under Important Information). Here is the link:

If you complete these forms fully, you have completed the requirements for any of the above-referenced Medicare Wellness codes.

Frequently Asked Questions:

What is the wRVU value of these codes?

G0402– 2.43 wRVU

G0438–2.43 wRVU

G0439– 1.50 wRVU

What diagnosis code do I use in conjunction with these Medicare Wellness billing codes?

Enter the V70.0 diagnosis code as usual

Then enter the appropriate Medicare Wellness billing code, as noted above

What are the pitfalls to avoid?

When denials are received from Medicare and/or a patient calls concerned that they received a bill when they thought they had come in for their covered “Wellness visit”, we review the clinical documentation to ensure that a code change is justified. We are finding that in most cases, the requirements for a Medicare Wellness visit are not being met and the code cannot be changed to a Medicare Wellness visit. If the patient was billed for a “sick visit” the patient is responsible for a copay. If the visit was billed as a regular preventive service, (99385-99397), the patient becomes responsible for the entire cost of the service as Medicare does not cover preventive exams.

To prevent this pitfall, bill the Medicare Wellness codes when appropriate, communicate to the patient that you are doing so, and document as required- being sure that each required form is fully completed.

What do I do if a patient comes in for a Wellness visit but also has a separate condition to evaluate/treat?

Should you provide a Medicare Wellness Visit as well as treat the patient for a separate condition, you may bill both a Medicare Wellness Visit and a Sick Visit (99201-99215). In this case, use the modifier 25 (for separate billable condition addressed at the same visit). The patient should be advised that he/she will be responsible for the visit copay.

If you have any questions, please feel free to contactKathy Brady at or at 508-334-1624.

Thank you.

David Fairchild, MD, MPH

Senior Vice President of Clinical Integration

UMass Memorial Health Care

Top View