Preventive care billing sits at the nexus of Medicare wellness codes, ACA-mandated screenings, and modifier-25 rules—a minefield of payer-specific requirements where a single coding error can erase an entire day's revenue. Verimedix brings the specialized expertise to code every preventive encounter correctly and capture every reimbursable service.
Preventive care billing divides into two distinct frameworks: Medicare and commercial/Medicaid. Medicare patients receive preventive services through specific HCPCS codes—G0402 (Welcome to Medicare/IPPE), G0438 (initial Annual Wellness Visit), and G0439 (subsequent AWV)—that are entirely separate from CPT preventive medicine codes (99381–99387 for new patients, 99391–99397 for established patients). Using the wrong code family for a payer is one of the most common and easily preventable denial triggers in preventive care billing. Medicare AWVs are covered at 100% with no patient cost-sharing, creating a patient access advantage that practices should actively leverage for care gap closure and screenings.
Same-day billing of a preventive visit with a problem-oriented E/M requires modifier -25 on the E/M code, with supporting documentation that clearly separates the two services. This applies across both Medicare and commercial payers. Additional preventive services that may be billed alongside an AWV include advance care planning (99497, 99498), alcohol screening and counseling (G0442, G0443), obesity counseling (G0447), depression screening (G0444, with a subsequent AWV but not the initial one), and—from CY2026—the optional physical activity and nutrition risk assessment (G0136), which replaced the social determinants of health (SDOH) risk assessment under the same code. Each add-on service requires a separate note and meets specific time or content requirements. The 2025 CMS update confirmed that G2211 can be billed with an E/M performed on the same day as an AWV when documentation supports a separately identifiable ongoing-relationship visit.
ACA-compliant commercial plans must cover USPSTF-recommended preventive services at no cost-sharing when billed with modifier -33. However, if a provider bills the preventive service and a problem-oriented E/M on the same visit, the E/M may be subject to cost-sharing unless the clinical record makes clear the two services are distinct. Practices that fail to apply modifier -33 on commercial preventive claims forfeit the patient cost-sharing waiver and may face member complaints. Navigating these nuances—Medicare vs. commercial coding, add-on service documentation, same-day modifier rules—requires billing expertise that generalist staff often lack.
Below are commonly billed codes our certified coders manage for preventive care practices. Always confirm payer-specific coverage and current code values.
| Code | Description | Billing note |
|---|---|---|
G0402 | Welcome to Medicare Initial Preventive Physical Examination (IPPE) | Once per lifetime, within the first 12 months of Part B coverage; includes education, counseling and referrals—the once-in-a-lifetime screening ECG is not part of G0402 and is billed separately as G0403 (complete), G0404 (tracing only) or G0405 (interpretation and report only) |
G0438 | Initial Annual Wellness Visit (AWV), first AWV after IPPE window | Billable once per lifetime after G0402 window; includes health risk assessment and personalized prevention plan |
G0439 | Subsequent Annual Wellness Visit (AWV) | Billable annually after G0438; at least 12 months must have elapsed since last AWV |
99397 | Periodic comprehensive preventive visit, established patient ages 65+, non-Medicare | Use for commercial/Medicaid payers; do NOT use for Medicare patients |
99497 | Advance Care Planning, first 30 minutes (≥16 min required) | Billable as optional add-on to AWV; fully covered with no patient cost-sharing when billed with AWV and modifier -33 |
G0444 | Annual depression screening, 5 to 15 minutes | Not separately payable with the IPPE (G0402) or the initial AWV (G0438), which already include a depression risk review (NCCI edits, per Noridian); billable with a subsequent AWV (G0439), once every 12 months |
G0447 | Face-to-face obesity counseling visit, 15 minutes | Billable as add-on to IPPE or AWV; requires BMI ≥30 and separate documentation |
G0442 | Annual alcohol misuse screening, 5 to 15 minutes | Must be billed together with G0443 when counseling is provided; each requires separate note |
G0136 | Physical activity and nutrition risk assessment (standardized, evidence-based), 5–15 minutes | Redefined for CY2026 (through 2025 it was the SDOH risk assessment); optional AWV element—cost-sharing waived once a year with modifier -33 on the same-day AWV claim; billed with an E/M or behavioral health visit instead, it is covered every 6 months and cost-sharing applies |
Our standard operating procedures for preventive care revenue cycle management — the step-by-step workflow we follow on every claim:
These are the issues we see most often in preventive care billing — and exactly how we resolve them:
Billing 99397 instead of G0438/G0439 for Medicare patients triggers outright denial. Fix: Build a payer-specific routing rule in the billing system so Medicare AWVs are automatically mapped to the appropriate HCPCS code based on documented AWV history.
Without modifier -25, the problem-oriented E/M is bundled into the preventive visit fee and denied. Fix: Implement a hard stop in the claim scrubbing workflow: any claim pairing a preventive code with an E/M code on the same date must carry modifier -25 on the E/M.
Practices perform ACP, the physical activity and nutrition risk assessment (G0136), or obesity counseling during the AWV but fail to bill the companion codes, leaving reimbursement uncaptured. Fix: Create an AWV encounter template that prompts providers to document and charge for each add-on service performed; train staff on the separate note requirements for each code.
NCCI edits make annual depression screening (G0444) not separately payable with the IPPE (G0402) or the initial AWV (G0438), because both visits already include a review of depression risk factors (CMS IPPE and AWV pages; Noridian). Fix: Build a claim edit that holds G0444 when G0402 or G0438 is on the same date; allow G0444 with G0439 or on its own, no more than once every 12 months.
Failure to append modifier -33 means the patient is billed cost-sharing for a service that should be free, triggering member disputes and potential compliance risk. Fix: Auto-apply modifier -33 to all preventive CPT codes (99381–99397) when the payer is identified as ACA-compliant commercial.
Verimedix works inside the systems preventive care practices already use, including:
G0402 (IPPE) is the Welcome to Medicare visit, available once within the first 12 months of Part B enrollment. G0438 is the Initial Annual Wellness Visit, available once after the IPPE window has closed and the patient has not previously had an AWV. G0439 is the Subsequent Annual Wellness Visit, used for all annual wellness visits after G0438. Only one AWV code may be billed per 12-month period per patient.
Yes, when a separately identifiable, medically necessary problem-oriented service is performed beyond the scope of the AWV. Append modifier -25 to the E/M code and document the distinct evaluation in the clinical note. Do not add modifier -25 to the AWV code itself.
Original Medicare does not cover routine annual physicals. It covers the Welcome to Medicare visit (G0402), Annual Wellness Visits (G0438/G0439), and specific preventive screenings. Some Medicare Advantage plans offer additional preventive benefits, including routine physicals, under plan-specific rules.
The AWV clinical note must include: a health risk assessment, updated medical and family history, vital signs, a list of current providers and suppliers, cognitive impairment screening, a review of potential risk factors for depression, a written screening schedule, and a personalized prevention plan. Advance care planning (99497) and the physical activity and nutrition risk assessment (G0136) are optional elements, separately billable when performed; bill them with modifier -33 on the same-day AWV claim so Medicare waives the patient's deductible and coinsurance.
Modifier -33 signals to ACA-compliant commercial payers that the service is a USPSTF-recommended preventive service, which must be covered at 100% with no cost-sharing. Apply it to the preventive CPT code (99381–99397) rather than the E/M code. If a problem-oriented E/M is also billed with modifier -25, that E/M may still carry cost-sharing.
Yes. Medicare allows AWVs (G0438 and G0439) to be provided via telehealth. Use the appropriate telehealth place-of-service code (POS 02 or POS 10) and modifier -95 for synchronous audio/video visits. Confirm that all required AWV documentation elements can be completed in the virtual setting.
Verimedix handles the entire preventive care revenue cycle — coding, submission, denials, and A/R — so your team can focus on patients.