Q&A: Comprehensive Physical Exams and Annual Wellness Visits

What annual comprehensive physical exam codes are covered?

The following CPT code ranges for new and established patients are covered for all HealthTeam Advantage members: 99385-99395. 

What “Welcome to Medicare” and Annual Wellness Visit (AWV) codes are covered?

The covered G codes are as follows: G0402 (initial preventive physical exam, aka Welcome to Medicare), G0438 (First Annual Wellness Visit), and G0439 (Subsequent Annual Wellness Visit). 

Are there any copays or coinsurances for these services?

There are no copays for In-Network providers for the comprehensive physical exam, annual wellness visits, or the “Welcome to Medicare” preventive visit. 

Note: A coinsurance/copay may be applied if the patient receives treatment for an illness during the annual physical visit. When billing for an E&M visit on the same day as these services, modifier 25 must be billed for both services to be considered. The member must be educated on any coinsurance/copay that may apply to services billed outside their routine physical/AWV. 

How many services are covered and how often?

HealthTeam Advantage allows these services once per calendar year. That means no need to wait exactly 12 months to schedule. 

The “Welcome to Medicare” preventive visit is a one-time visit and is only covered within the first 12 months the member has Medicare Part B. If G0402 is not performed within the 12-month window, skip G0402 and go straight to G0438 instead. 

If the member has had Part B for longer than 12 months, they can get an annual wellness visit covered once each calendar year.  

Note: The first annual wellness visit cannot take place within 12 months of the “Welcome to Medicare” preventive visit. However, the member does not need to have the “Welcome to Medicare” visit to be covered for their annual wellness visits after having had Part B for 12 months.  

Comprehensive physical exams are also covered once per calendar year.   

Both comprehensive physical exams and annual wellness visits can be performed on the same day. A modifier (such as modifier -25) may be required when billing both services on the same date. 

What should not be billed along with these services?

When billing for the comprehensive physical exams or the annual wellness visits, it is important not to bill with a GY modifier. A GY modifier indicates that “an item or service statutorily excluded or does not meet the definition of any Medicare.” Billing a GY modifier along with these covered services is inappropriate. Should you append a GY modifier, the services will automatically process as non-covered and put the entire financial liability on the member.  Please DO NOT bill a GY modifier when submitting claims for a physical exam or AWV. 

Is there anything additional I should know?

Effective in 2024, a new Place-of-Service (10) was created to state where the telehealth visit occurred.   

Since the G0438 (AWV, Initial) and G0439 (AWV, subsequent) are payable as a telehealth visit and because a new POS was created, we recommend providers update their billing software to include the following: 

CPT/HCPCS Code	Modifier	POS
G0438	95 – synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system  OR  93 – Audio-Only Telehealth	10
G0439	95 – synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system  OR  93 – Audio-Only Telehealth	10
G0438	N/A	02
G0439	N/A	02

Note: If you bill the service G0438/G0439 with modifier 95/93 in POS 02, the claim will be denied due to the modifier and HCPCS mismatch. 

The Risk Adjustment Team requests that providers document the service as audio only when it occurred and to use modifier 93 when applicable. Risk adjustment services must always be face-to-face, and we need to know what services are not face-to-face. 

CMS documentation for the AWV: https://www.cms.gov/medicare/prevention/prevntiongeninfo/medicare-preventive-services/mps-quickreferencechart-1.html