As the official codes used to reimburse billing practitioners for providing Medicare annual wellness visits (AWVs), HCPCS codes G0438 and G0439 are used by a wide spectrum of healthcare providers, from physicians and physician assistants (PAs) to nurse practitioners (NPs) and pharmacists. But they’re also frequently misused. To help protect providers against denied claims, let’s take a deeper dive into the details of G0438 and G0439 and how they should be used.

Definition of HCPCS codes G0438 and G0439

As we explained in our recent overview of annual wellness visits, HCPCS G0438 and G0439 are used to bill for these important yearly interactions — which are not the same as a yearly patient checkup, but a means to encourage preventive care by offering patients a free visit with their primary care provider to “develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA),” as per the official guide from the Centers for Medicare & Medicaid Services (CMS).

What is a Medicare annual wellness visit? Get a primer on AWVs here

Introduced in 2011, G0438 and G0439 have become a core part of the patient care ecosystem in the years since. Annual wellness visits are performed primarily by doctors or other qualified health care professionals (QHPs), which includes PAs, NPs and clinical nurse specialists (CNS). And, if they’re working under a physician or QHP’s direct supervision, other licensed practitioners like registered dietitians, health educators and pharmacists can also perform AWVs — and in doing so, they can help improve the prospect of positive patient health outcomes.

“An AWV with a pharmacist can have a significant impact on patient outcomes,” according to a Medical Economics overview of pharmacist-conducted annual wellness visits. “In a 3-month study evaluating 300 patient records, clinical pharmacists completed an average of 5.4 interventions, made 272 referrals, ordered 183 diabetes and lipid screenings, offered 370 vaccinations, and made 24 medication and dosage changes during the AWV.”

As the primary reimbursement codes for annual wellness visits, G0438 and G0439 have two primary requirements for patient eligibility:

  • They can be used only once every 12 months, and
  • The service is free to patients, as long as their provider accepts the care responsibility.

Let’s take a closer look at each of these individual codes.

What is HCPCS code G0438, and how should it be used?

HCPCS code G0438 is used to reimburse healthcare providers for a patient’s first annual wellness visit, provided that the patient has been enrolled in Medicare Part B for more than 12 months and has not received another AWV or initial preventive physical exam (IPPE) in the prior 12 months. If the patient meets these criteria, HCPCS G0438 can be used to reimburse a patient’s first AWV — but can only be used just once in a patient’s lifetime.

According to the current Code of Federal Regulations (CFR), this “first annual wellness visit” covered by G0438 can include the following services:

  • Review and administration (as needed) of the patient’s HRA
  • Establishing the patient’s “medical and family history”
  • Establishing what “current providers and suppliers” are regularly involved in the patient’s medical care
  • Taking routine measurements like height, weight and blood pressure “as deemed appropriate”
  • Detecting potential cognitive impairment
  • Reviewing risk factors/past experiences with “depression or other mood disorders”
  • Reviewing the patient’s “functional ability and level of safety”
  • Establishing a written screening schedule, listing risk factors and conditions “for which primary, secondary or tertiary interventions are recommended or are underway”
  • Furnishing personalized health advice to the patient, and referring education or counseling services or programs, as appropriate
  • Providing advance care planning services, which can include “discussion about future care decisions”
  • Reviewing any current opioid prescriptions
  • Screening for substance use disorders
  • “Any other element determined appropriate through the national coverage determination process”

What is HCPCS code G0439, and how should it be used?

So, how is it that an “annual” wellness visit can only be billed once in a beneficiary’s lifetime, as we’ve seen under the G0438 requirements? That’s where HCPCS code G0439 comes in. After G0438 has been used for a patient’s first AWV, each one after that — which Medicare Part B patients are eligible for once each year — should be billed using G0439.

As such, G0439 can only be used after 12 months have passed since G0438 was used for a patient. According to CMS guidelines, this means that patients are eligible on the first day of the same month the next calendar year. So, if a provider billed HCPCS code G0438 or G0438 for a certain patient on July 15, 2022, that same beneficiary would become eligible for G0439 again on July 1, 2023.

Beyond that, the CFR defines eligible service for G0439’s “subsequent” annual wellness visits as mostly the same as the list above for G0438. The main difference is that services designed to “establish” certain aspects of the patient’s care needs — such as medical history and risk factors — can now be used to update that information.

For patients who have been Medicare beneficiaries for less than the 12 months, providers should use HCPCS code G0402. This provides reimbursement for the Welcome to Medicare visit, or the Initial Preventative Physical Exam (IPPE). It’s also important to note that federally qualified health clinics (FQHC) must use G0468 instead of either G0438 or G0439 to bill for annual wellness visits.

What else should healthcare providers know about G0438 and G0439?

The challenge to properly using G0438 and the other AWV codes lies in establishing just which one to use at any given time. Indeed, G0438 seems to be among the codes that receive frequent denials from CMS for just this reason. There are a few persistent reasons for these denials, including:

  • Billing for patients who don’t have Part B coverage;
  • Billing G0438 before the patient has been a Part B enrollee for a full year;
  • Billing under G0439 before G0438 has been used;
  • Billing G0438 or G0439 instead of G0402 for new Medicare beneficiaries; and/or
  • Using an incorrect code for primary diagnosis.

Regarding that last point, if the “primary diagnosis code is problem-oriented (e.g., diabetes or hypertension), Medicare will most likely deny a claim for an AWV, because AWVs are ‘well visits,’” explains Vinita Magoon, DO, JD, MBA, MPH, CMQ in an FAQ on annual wellness visits published by the American Academy of Family Physicians (AAFP).

“Instead, list a well code (e.g., Z00.0X, “encounter for general adult exam”) as the primary diagnosis,” the AAFP report advises. “The IPPE also has a slightly different set of required components (e.g., advance care planning and visual acuity screening with documentation of results in the note) than the two types of AWVs (e.g., instrumental activity of daily living and assessment of cognitive function).”

Providers should also remember not to bill either G0438 or G0439 within 12 months of billing G0402, G0438 or G0439 for the same patient. “You can only bill G0438 or G0439 once in a 12-month period,” the CMS manual points out. It also advises providers not to bill “G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient,” since that will result in a denied claim.

However, providers can receive reimbursement for G0438 or G0439 in conjunction with other evaluation and management (E&M) services. According to CMS, these procedures must be “medically necessary and reasonable to treat the patient’s illness or injury, or to improve the functioning of a malformed body part.” In these cases, “the additional CPT code with modifier –25” should be used.

As we noted in our overview of annual wellness visits, G0438 or G0439 can be paired with other Part B preventive services such as screenings for cancer or depression, counseling and education for tobacco use, and a variety of other options. Refer to the CMS guide for a full list of these services.

Finally, one of the most challenging aspects of using the right code is understanding whether G0438 or G0439 has been used for a Medicare beneficiary by different care providers. Practices that take on new patients are responsible for determining whether those codes have already been used for that beneficiary — a process of checking claims data that can take some extra work and investigation.

Deliver G0438 and G0439 remotely with telehealth technology

During the ongoing Covid-19 public health emergency (PHE) — and possibly even after it ends — CMS is allowing G0438 and G0439 to be delivered remotely, waiving its earlier in-person requirements. To discover how remote care technology can help your organization deliver this vital service, contact CareSimple to connect with an expert.

And for more reimbursement details for G0438, G0439 and other HCPCS and CPT® codes and care management models, download our CareSimple Reimbursement Tree for a handy, one-page summary.