Annual Wellness Visit Health Risk Assessment

The annual wellness visit (AWV) includes a health risk assessment (HRA). View the following summary of HRA minimum elements. A Framework for Patient-Centered Health Risk Assessments has more information, including a sample HRA.

First AWV Components

Action	Elements
Perform an HRA	Get patient self-reported information. You or the patient can update the HRA before or during the AWV. Consider the best way to communicate with underserved populations, people who speak different languages, people with varying health literacy, and people with disabilities. At a minimum, collect this information: Demographic data Health status self-assessment Psychosocial risks, including, but not limited to, depression, life satisfaction, stress, anger, loneliness or social isolation, pain, and fatigue Behavioral risks, including, but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (for example, seat belt use), and home safety Activities of daily living (ADLs), including, but not limited to, dressing, feeding, toileting, grooming, physical ambulation (including balance or fall risks), and bathing Instrumental ADLs (IADLs), including, but not limited to, using the phone, food preparation, housekeeping, laundry, transportation, shopping, managing medications, and handling finances
1. Establish the patient’s medical and family history	At a minimum, document: Medical events of the patient’s parents, siblings, and children, including hereditary conditions that place them at increased risk Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments) Use of, or exposure to, medications, supplements, and other substances
2. Establish a current providers and suppliers list	Include current patient providers and suppliers who regularly provide medical care, including behavioral health care.
3. Measure	Measure: Height, weight, body mass index (or waist circumference, if appropriate), and blood pressure Other routine measurements as deemed appropriate, based on medical and family history
4. Detect any cognitive impairments the patient may have	Check for cognitive impairment as part of the first AWV. Assess cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others. Consider using brief cognitive tests, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Alzheimer’s and Related Dementias Resources for Professionals has more information.
5. Review the patient’s potential depression risk factors	Depression risk factors include: Current or past experiences with depression Other mood disorders Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. The American Psychological Association’s Depression Assessment Instruments has more information.
6. Review the patient’s functional ability and level of safety	Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the patient’s: Ability to perform ADLs Fall risk Hearing impairment Home and community safety, including driving when appropriate Medicare offers cognitive assessment and care plan services for patients who show signs of impairment.
7. Establish an appropriate written screening schedule	Base the written screening schedule on the: Checklist for the next 5–10 years U.S. Preventive Services Task Force and Advisory Committee on Immunization Practices (ACIP) recommendations Patient’s HRA, health status, screening history, and age-appropriate preventive services we cover
8. Establish the patient’s list of risk factors and conditions	Include: A recommendation for primary, secondary, or tertiary interventions, or report whether they’re underway Mental health conditions, including depression, substance use disorders, and cognitive impairments Initial preventive physical exam (IPPE) risk factors or identified conditions Treatment options and associated risks and benefits
9. Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs	Include referrals to educational and counseling services or programs aimed at community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including: Fall prevention Nutrition Physical activity Tobacco-use cessation Social engagement Weight loss Cognition
10. Provide advance care planning (ACP) services at the patient’s discretion	ACP is a discussion between you and the patient about: Preparing an advance directive in case an injury or illness prevents them from making their own health care decisions Future care decisions they might need or want to make How they can let others know about their care preferences Caregiver identification Advance directive elements, which may involve completing standard forms Advance directive is a general term that refers to various documents, like a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent or records a patient’s wishes about their medical treatment at a future time when the patient can’t communicate for themselves. Advance Care Planning has more information. We don’t limit how many times the patient can revisit the ACP during the year, but cost sharing applies outside the AWV.
11. Review current opioid prescriptions	For a patient with a current opioid prescription: Review any potential opioid use disorder (OUD) risk factors Evaluate the patient’s pain severity and current treatment plan Provide information about non-opioid treatment options Refer the patient to a specialist, as appropriate The HHS Pain Management Best Practices Inter-Agency Task Force Report has more information. Medicare now covers monthly chronic pain management and treatment services.
12. Screen for potential substance use disorders (SUDs)	Review the patient’s potential SUD risk factors, and refer them for treatment as appropriate. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is another resource.
13. Conduct Social Determinants of Health (SDOH) Risk Assessment	Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and make sure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate. Medicare Claims Processing Manual, Chapter 18, section 140.9 has more information.

Subsequent AWV Components

Action	Elements
1. Review and update the HRA	Get patient self-reported information. You or the patient can update the HRA before or during the AWV. At a minimum, collect this information: Demographic data Health status self-assessment Psychosocial risks, including, but not limited to, depression, life satisfaction, stress, anger, loneliness or social isolation, pain, and fatigue Behavioral risks, including, but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (for example, seat belt use), and home safety ADLs, including, but not limited to, dressing, feeding, toileting, grooming, physical ambulation (including balance or fall risks), and bathing IADLs, including, but not limited to, using the phone, food preparation, housekeeping, laundry, transportation, shopping, managing medications, and handling finances
2. Update the patient’s medical and family history	At a minimum, document updates to: Medical events of the patient’s parents, siblings, and children, including hereditary conditions that place them at increased risk Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments) Use of, or exposure to, medications, supplements, and other substances
3. Update current providers and suppliers list	Include current patient providers and suppliers who regularly provide medical care, including those added because of the first AWV’s personalized prevention plan services (PPPS), and any behavioral health providers.
4. Measure	Measure: Weight (or waist circumference, if appropriate) and blood pressure Other routine measurements as deemed appropriate, based on medical and family history
5. Detect any cognitive impairments the patient may have	Check for cognitive impairment as part of the subsequent AWV. Assess cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others. Consider using brief cognitive tests, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Alzheimer’s and Related Dementias Resources for Professionals has more information.
6. Update the patient’s written screening schedule	Base the written screening schedule on the: U.S. Preventive Services Task Force and ACIP recommendations Patient’s HRA, health status and screening history, and age-appropriate preventive services we cover
7. Update the patient’s list of risk factors and conditions	Include: A recommendation for primary, secondary, or tertiary interventions, or report whether they’re underway Mental health conditions, including depression, substance use disorders, and cognitive impairments Risk factors or identified conditions Treatment options and associated risks and benefits
8. As necessary, provide and update patient PPPS, including personalized health advice and appropriate referrals to health education or preventive counseling services or programs	Include referrals to educational and counseling services or programs aimed at community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including: Fall prevention Nutrition Physical activity Tobacco-use cessation Social engagement Weight loss Cognition
9. Provide ACP services at the patient’s discretion	ACP is a discussion between you and the patient about: Preparing an advance directive in case an injury or illness prevents them from making their own health care decisions Future care decisions they might need or want to make How they can let others know about their care preferences Caregiver identification Advance directive elements, which may involve completing standard forms Advance directive is a general term that refers to various documents, like a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. Advance Care Planning has more information. We don’t limit how many times the patient can revisit the ACP during the year, but cost sharing applies outside the AWV.
10. Review current opioid prescriptions	For a patient with a current opioid prescription: Review any potential OUD risk factors Evaluate the patient’s pain severity and current treatment plan Provide information about non-opioid treatment options Refer the patient to a specialist, as appropriate The HHS Pain Management Best Practices Inter-Agency Task Force Report has more information. Medicare now covers monthly chronic pain management and treatment services.
11. Screen for potential SUDs	Review the patient’s potential SUD risk factors, and refer them for treatment as appropriate. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is another resource.
12. Conduct SDOH Risk Assessment	Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and make sure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate. Medicare Claims Processing Manual, Chapter 18, section 140.9 has more information.

Preparing Eligible Patients for Their AWV
Help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment: Medical records, including immunization records Detailed family health history Full list of medications and supplements, including calcium and vitamins, how often the patient takes them, and how much of each they take Full list of current providers and suppliers involved in the patient’s care, including community-based providers (for example, those providing personal care, adult day care, and home-delivered meals) and behavioral health specialists

Preparing Eligible Patients for Their AWV

Help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment:

Medical records, including immunization records
Detailed family health history
Full list of medications and supplements, including calcium and vitamins, how often the patient takes them, and how much of each they take
Full list of current providers and suppliers involved in the patient’s care, including community-based providers (for example, those providing personal care, adult day care, and home-delivered meals) and behavioral health specialists

AWV Coding, Diagnosis & Billing

Coding

Use these HCPCS codes to file AWV claims:

AWV HCPCS Codes	Billing Code Descriptors
G0438	Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit
G0439	Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit
G0468*	Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV

* You must provide an AWV or IPPE with a standard bundle of services available to all patients. Get more information in Medicare Claims Processing Manual, Chapter 9, section 60.2.

Diagnosis

Report a diagnosis code when submitting AWV claims. We don’t require you to use a specific AWV diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Billing

Part B covers an AWV if it’s performed by a:

Physician (doctor of medicine or osteopathy)
Qualified non-physician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist)
Medical professional (including health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of medical professionals directly supervised by a physician

When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV, and G0439 is for subsequent AWVs. Don’t bill G0438 or G0439 within 12 months of billing HCPCS code G0402 (IPPE) for the same patient. We deny these claims with messages indicating the patient reached the benefit maximum for the period.

We pay for G0438 and G0439 when you provide services via telehealth.

ACP as an Optional AWV Element

ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a patient to discuss their health care wishes and medical treatment preferences if they become unable to communicate or make decisions about their care. At the patient’s discretion, you can provide the ACP during the AWV.

Coding

Use these CPT codes to file ACP claims as an optional AWV element:

ACP CPT Codes	Billing Code Descriptors
99497	Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
99498	Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Diagnosis

Report a diagnosis code when submitting an ACP claim as an optional AWV element. We don’t require you to use a specific ACP diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with the patient’s exam.

Billing

We waive both the Part B ACP coinsurance and deductible when it’s:

Delivered on the same day by the same AWV provider
Billed with modifier 33 (Preventive Services) on the same AWV claim

We waive the ACP deductible and coinsurance once per year when billed with the AWV. If we deny the AWV billed with ACP for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance.

We apply the deductible and coinsurance when you deliver the ACP outside the covered AWV. There are no limits on the number of times you can report ACP for a certain patient in a certain period. When billing this service multiple times, document changes in the patient’s health status or wishes about their end-of-life care.

SDOH Risk Assessment as an Optional AWV Element

SDOH is important in:

Assessing patient histories
Assessing patient risk
Guiding medical decision making, prevention, diagnosis, care, and treatment

In the CY 2024 Medicare Physician Fee Schedule final rule, we added a new SDOH Risk Assessment as an optional, additional element of the AWV. At both your and the patient’s discretion, you may conduct the SDOH Risk Assessment during the AWV.

Coding

Use this HCPCS code to file SDOH Risk Assessment claims as an optional AWV element:

SDOH Risk Assessment HCPCS Code	Billing Code Descriptor
G0136	Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5–15 minutes

Diagnosis

Report a diagnosis code when submitting an SDOH Risk Assessment claim as an optional AWV element. We don’t require you to use a specific SDOH Risk Assessment diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with the patient’s exam.

Billing

For the SDOH Risk Assessment, we waive both the Part B coinsurance and deductible when it’s:

Provided on the same day by the same AWV provider
Billed with modifier 33 (Preventive Services) on the same AWV claim

We cover G0136 once every 6 months when you provide an evaluation and management or behavioral health service on the same claim with the same date of service, in which case the patient’s deductible and coinsurance apply.

We waive the SDOH Risk Assessment deductible and coinsurance once per year when billed with the AWV.

If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when you deliver the SDOH Risk Assessment outside the covered AWV.

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Page Last Modified:

11/14/2025 08:32 AM

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