## **What is a subsequent annual wellness visit?**
HCPCS code G0439 represents a subsequent annual wellness visit (AWV) under Medicare Part B. This service follows the initial AWV (G0438) and must be performed at least 12 full months after the prior AWV or Initial Preventive Physical Examination (IPPE, G0402).
G0439 visits include updating the Health Risk Assessment (HRA), reviewing and refreshing medical and family history, screening schedule, functional status, cognitive function, risk factors, and personalized prevention plan all aimed at maintaining and refining preventive health efforts annually. These visits are 100% covered by Medicare, with no deductible, coinsurance, or copayment, provided the patient is eligible.
## **HCPCS code G0439 documentation requirements**
Documentation must demonstrate that the visit was completed, support medical necessity, and provide evidence for the preventive services delivered.
Required documentation includes:
- Beneficiary’s name and date of service (DOS)
- Since this is a subsequent AWV, progress notes must include:
Review and administration (if needed) of updated health risk assessment
Updated patient's medical history along with family history
Updated list of providers and suppliers
Updated use of medications and supplements
Repeat depression and cognitive impairment screening (for mental health conditions)
Updated patient's functional ability and safety evaluation (hearing impairment, ability to successfully perform activities of daily living, fall risk, home safety)
Revised screening schedule for preventive testing
Updated list of risk factors and conditions
Follow-up educational counseling for health risks
- Appropriate signatures and credentials of the provider rendering services
## **G0439 billing requirements**
- G0439 may only be billed once annually, and only after the initial AWV (G0438) has been performed.
- Patient must have active Part B coverage. Medicare provides this wellness visit without cost-sharing.
- G0439 may be provided via telehealth, per CMS policy.
- If a separately identifiable, medically necessary E/M service is performed on the same day, practitioners may bill it with modifier –25 in addition to G0439. The E/M service is subject to cost-sharing, even though G0439 itself is not.
## **Other relevant codes**
- **G0438** – Initial annual wellness visit; includes a personalized prevention plan of service (PPPS),
- **G0402** – Initial Preventive Physical Exam (IPPE) (“Welcome to Medicare” visit): Billed within first 12 months of Part B enrollment—after this, use G0438 or G0439.
- **Z00.0X (or similar codes in Z00 category)**: Example of a wellness encounter diagnosis, appropriate as the primary diagnosis for AWV.
- **G0434** - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
- **G0444** - Annual depression screening, 5 to 15 minutes
Frequently asked questions
