What is the ICD-10 code for a Medicare Annual Wellness Visit?

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The primary ICD-10-CM codes for a Medicare Annual Wellness Visit (AWV) are Z00.00 (without abnormal findings) and Z00.01 (with abnormal findings).

Primary ICD-10 Codes

  • Z00.00: Encounter for general adult medical examination without abnormal findings. Use this code when chronic conditions are stable, improving, or absent.
  • Z00.01: Encounter for general adult medical examination with abnormal findings. Use this code if a new abnormality or unstable issue is discovered during the encounter, and report additional specific diagnosis codes for any conditions addressed.

Associated Medicare CPT/HCPCS Codes

An AWV must be billed using specific Medicare HCPCS codes rather than standard commercial physical exam codes:

  • G0402: Initial Preventive Physical Examination (IPPE) / "Welcome to Medicare" visit (one-time benefit within the first 12 months of Part B enrollment).
  • G0438: Initial Annual Wellness Visit (first AWV after being enrolled in Part B for more than 12 months; a once-in-a-lifetime benefit).
  • G0439: Subsequent Annual Wellness Visit (yearly recurring follow-up visit).

You can review official guidelines and details through the CMS Medicare Wellness Visits Guide.

What are the CMS guidelines for annual wellness visits in 2026?

The Centers for Medicare & Medicaid Services (CMS) guidelines for a Medicare Annual Wellness Visit (AWV) in 2026 focus on personalized prevention planning, risk assessments, and health status updates rather than a head-to-toe physical examination.

Core HCPCS / CPT Codes & Eligibility

  • G0402 (IPPE / Welcome to Medicare): Covered once in a lifetime for new beneficiaries within their first 12 months of Part B enrollment (National average reimbursement: ~$175).
  • G0438 (Initial AWV): Available once in a lifetime for patients who have been enrolled in Part B for more than 12 months and have not received an initial AWV or IPPE (National average reimbursement: ~$174).
  • G0439 (Subsequent AWV): Billed annually, at least 11 full calendar months after the previous initial or subsequent AWV (National average reimbursement: ~$138).

Key 2026 Updates

  • Physical Activity & Nutrition Assessment (G0136): Effective in 2026, a standardized, evidence-based assessment of physical activity and nutrition (lasting 5 to 15 minutes) can be billed using code G0136 semi-annually as an optional element. Add modifier -33 on the claim alongside the AWV to waive the copayment and deductible for this specific code.
  • Cost Sharing: The AWV itself remains a $0 preventive service for beneficiaries if the provider accepts assignment. However, addressing acute or new medical issues during the same visit may trigger a separate Evaluation and Management (E/M) charge subject to deductibles and coinsurance (use modifier -25).

Required Documentation Elements

  • Health Risk Assessment (HRA): Completed by or on behalf of the beneficiary prior to or during the visit.
  • Medical and Family History: Documenting past medical events of parents, siblings, and children, along with hereditary risk factors.
  • Current Providers & Suppliers List: A list of regular medical and behavioral healthcare providers.
  • Routine Measurements: Height, weight, body mass index (BMI) or waist circumference, and blood pressure.
  • Cognitive Impairment Detection: Assessed via direct observation or formal screening instruments.
  • Depression & Functional Screening: Reviewing risk of depression, functional ability, fall risks, and home safety.
  • Personalized Prevention Plan (PPPS): A written schedule or checklist of recommended preventive services and screenings for the coming years.

How to code a Medicare annual wellness visit?

To code a Medicare Annual Wellness Visit (AWV), use HCPCS code G0438 for an initial visit or G0439 for a subsequent yearly visit.

Core HCPCS/CPT Codes

  • G0402: Initial Preventive Physical Examination (IPPE / "Welcome to Medicare" exam)—only within the first 12 months of Part B enrollment.
  • G0438: Initial Annual Wellness Visit—first visit after being enrolled in Part B for more than 12 months (or if the IPPE window was missed).
  • G0439: Subsequent Annual Wellness Visit—yearly follow-up conducted at least 11 months after the initial AWV.
  • G0136: Administration of a standardized, evidence-based Social Determinants of Health (SDOH) risk assessment (5–15 minutes).

Diagnosis Coding (ICD-10)

  • Z00.00: Encounter for general adult medical examination without abnormal findings.
  • Z00.01: Encounter for general adult medical examination with abnormal findings.
  • Note: Report additional specific ICD-10 codes for any stable chronic or acute conditions managed or evaluated during the encounter.

Key Billing and Documentation Rules

  • Health Risk Assessment (HRA): Required for both initial and subsequent visits; must be completed by the patient or caregiver prior to or during the visit.
  • Same-Day Sick Visits: If a separate, medically necessary Evaluation and Management (E/M) service (e.g., 99213) is performed during the same encounter, append modifier -25 to the E/M code. Do not append modifiers to the wellness HCPCS code.
  • No Cost-Sharing: AWVs are covered at 100% by Medicare with zero patient deductible or coinsurance when billed with the appropriate preventive diagnosis codes.

What are the CMS guidelines for Medicare annual wellness visits?

CMS guidelines for Medicare Annual Wellness Visits (AWV) outline a yearly, $0 cost-sharing preventive appointment designed to create or update a personalized prevention plan.

Eligibility and Frequency

  • Initial AWV (G0438): Available to Part B beneficiaries who have had their Part B coverage for more than 12 months, and have not received an initial AWV or an Initial Preventive Physical Exam (IPPE/Welcome to Medicare visit) in the past 12 months.
  • Subsequent AWV (G0439): Available once every 12 months (at least 11–12 months after the previous initial or subsequent AWV).
  • Provider Requirements: Must be performed by a physician, physician assistant, nurse practitioner, clinical nurse specialist, or under direct supervision.

Initial AWV Requirements

  • Health Risk Assessment (HRA): Completed by the patient or provider covering demographics, self-assessed health, psychosocial/behavioral risks, and activities of daily living (ADLs).
  • Medical and Family History: Documenting family medical events, past medical/surgical history, and current medications/supplements.
  • Provider List: Establish a list of current medical providers and suppliers regularly involved in care.
  • Routine Measurements: Height, weight, body mass index (BMI), blood pressure.
  • Cognitive Screening: Check for cognitive impairment through direct observation or reporting.
  • Depression & Functional Screening: Review risk factors for depression and assess functional safety/ability.
  • Personalized Plan: Establish a written screening schedule (checklist) for the next 5 to 10 years and offer health advice or referrals.

Subsequent AWV Requirements

  • Updates: Update the HRA, medical/family history, provider list, and written screening schedule.
  • Assessments: Re-evaluate routine measurements, cognitive function, and depression risk factors.
  • Interventions & Advice: Update the list of risk factors/conditions for interventions and provide personalized health advice or preventive referrals.
  • Advance Care Planning: Discuss advance directives optionally at the patient's discretion.

Is CPT code 99397 used for an annual wellness visit?

CPT code 99397 is used for a routine annual preventive physical exam for an established patient who is 65 years of age or older, but it is not used for a standard Medicare Annual Wellness Visit (AWV).

Key Differences in Usage

  • Commercial and Medicaid Insurance: CPT 99397 is the correct code for a comprehensive routine annual physical/preventive exam for established patients aged 65+. It includes a full physical examination.
  • Traditional Medicare: Traditional Medicare does not accept CPT 99397 for an Annual Wellness Visit. Medicare requires HCPCS G-codes instead:
    • G0438: Initial Medicare Annual Wellness Visit
    • G0439: Subsequent Medicare Annual Wellness Visit
  • Scope of Service: A commercial preventive visit using CPT 99397 includes a head-to-toe physical examination, whereas a Medicare AWV focuses strictly on health risk assessments and prevention planning without a comprehensive physical exam.

Medicare AWV CPT Codes 2026 Update | Annual Wellness Visit Billing & Coding Guide

9 related questions found

What is the ICD-10 code for Medicare Wellness Visits?

The primary ICD-10-CM diagnosis codes for a Medicare wellness visit are Z00.00 (without abnormal findings) and Z00.01 (with abnormal findings).

ICD-10 Codes for Wellness Exams

  • Z00.00: Encounter for general adult medical examination without abnormal findings (used for routine preventive exams where no abnormalities are found).
  • Z00.01: Encounter for general adult medical examination with abnormal findings (used when the examination reveals new or active abnormalities).

Medicare Billing Context (HCPCS/CPT Codes)

While Z-codes provide the diagnosis reason for the preventive encounter, Medicare utilizes specific HCPCS/CPT codes to bill the actual service:

  • G0402: Initial Preventive Physical Examination (IPPE), or the "Welcome to Medicare" visit (one-time benefit within the first 12 months).
  • G0438: Initial Annual Wellness Visit (AWV) (once per lifetime, after the first year).
  • G0439: Subsequent Annual Wellness Visit (AWV) (recurring yearly visit).

For complete documentation details, consult the Medicare Annual Wellness Visit Documentation Guidelines.

Do Medicare wellness visits need to be 12 months apart?

Medicare covers an annual wellness visit once every 12 months, meaning at least 11 full months must pass between your previous visit and your next one.

Timing Rules

  • Original Medicare (Fee-for-Service): Subsequent annual wellness visits typically require at least 11 full months to have passed, and some billing systems measure based on the calendar month (for example, if your last visit was December 21, you can have the next one as early as December 1).
  • Medicare Advantage: These plans follow calendar-year rules in some cases, but visits should still ideally be spaced about 12 months apart to ensure smooth coverage.
  • First-Year Rules: Your very first annual wellness visit cannot happen within the first 12 months of your Part B enrollment or during the same window as a "Welcome to Medicare" physical.

You can check specific rules or locate your coverage details through the official Medicare Yearly Wellness Visits page.

What is the ICD-10 code for a yearly wellness exam?

The ICD-10 code for a yearly wellness exam or general adult medical examination without abnormal findings is Z00.00.

Key Codes for Wellness Exams

  • Z00.00: Encounter for general adult medical examination without abnormal findings (used for routine physicals or wellness checks when everything is normal or stable).
  • Z00.01: Encounter for general adult medical examination with abnormal findings (used if a new abnormality or issue is discovered during the exam).
  • Z00.129 / Z00.121: Used instead for routine child health exams (without or with abnormal findings).

Important Billing Notes

  • Diagnosis vs. Procedure: These ICD-10 codes describe the reason for the visit. You may also need a CPT code (like 99385–99397 for standard commercial insurance) or a HCPCS G-code (like G0438 or G0439 for Medicare Annual Wellness Visits) to bill for the actual service performed.
  • Medicare Rules: Medicare does not strictly mandate using Z00.00 for every Annual Wellness Visit; the diagnosis code should match the specific clinical documentation and services provided during the encounter.

Can you bill 99395 and 99214 together?

Yes, you can bill CPT code 99395 (preventive visit for an adult aged 18–39) and 99214 (established patient office/outpatient visit, moderate medical decision making) together, but only when a significant, separately identifiable medical service is performed during the same encounter.

Key Requirements for Combined Billing

  • Separate Reason: The patient must present with a distinct acute or chronic problem (such as evaluating new-onset hypertension or adjusting medications for an uncontrolled condition) that goes beyond the routine preventive exam.
  • Modifier 25: You must append Modifier 25 to the problem-oriented E/M code (99214), not the preventive code. This indicates that the problem-oriented work was separate and extra.
  • Distinct Documentation: The medical record must clearly separate the components. The exam or time spent on the preventive service (99395) cannot be double-counted to support the medical decision-making or time requirements of the 99214 code.

What are the three types of Medicare wellness visits?

The three types of Medicare wellness visits are the Initial Preventive Physical Exam (IPPE), the Initial Annual Wellness Visit (IAWV), and the Subsequent Annual Wellness Visit (SAWV).

1. Initial Preventive Physical Exam (IPPE) / "Welcome to Medicare" Visit

  • Timing: Must occur within the first 12 months of enrolling in Medicare Part B.
  • Frequency: Covered only once in a lifetime.
  • Focus: Reviews medical and social history, measures height, weight, and blood pressure, screens for depression, and provides education on preventive services. It may also include a baseline EKG/electrocardiogram.

2. Initial Annual Wellness Visit (IAWV)

  • Timing: Available after the first 12 months of having Medicare Part B, once the 12-month window for the IPPE has passed.
  • Frequency: Covered once in a lifetime as the starting point for yearly visits.
  • Focus: Establishes a personalized prevention plan, reviews medical and family history, and screens for cognitive impairment and health risk factors using a Health Risk Assessment (HRA) questionnaire.

3. Subsequent Annual Wellness Visit (SAWV)

  • Timing: Available at least 12 months after the Initial Annual Wellness Visit.
  • Frequency: Can be done once every 12 months going forward.
  • Focus: Updates your health risk assessment, medical/family history, and written screening schedule, while tracking changes in cognitive function and adjusting your long-term preventive care plan.

Note: None of these three options are traditional, head-to-toe physical exams with lab work or diagnostic testing; they are strictly designed for prevention planning. You can learn more details directly from the Centers for Medicare & Medicaid Services.