Exam performed without relationship to treatment or diagnosis of a specific illness, symptom, complaint, or injury.
✘ Medicare doesn’t cover a routine physical
✘ Patients pay 100% out-of-pocket
Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health:
As a health care provider, you may recommend that patients get services more often than we cover or that we don’t cover. If this happens, help patients understand they may have to pay some or all costs. Communication is key to ensuring patients understand why you’re recommending certain services and whether we cover them.
Initial Preventive Physical Exam
The initial preventive physical exam (IPPE), also known as the “Welcome to Medicare” preventive visit, promotes good health through disease prevention and detection. We pay for 1 IPPE per lifetime if it’s provided within the first 12 months after the patient’s Part B coverage starts.
1. Review the patient’s medical and social history
At a minimum, collect this information:
Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments)
Current medications, supplements, and other substances the person may be using
Family history (review the patient’s family and medical events, including hereditary conditions that place them at increased risk)
2. 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. APA’s Depression Assessment Instruments has more information.
3. Review the patient’s functional ability and safety level
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 activities of daily living (ADLs)
Fall risk
Hearing impairment
Home and community safety, including driving when appropriate
8. Educate, counsel, and refer based on previous components
Based on the results of the review and evaluation services from the previous components, provide the patient with appropriate education, counseling, and referrals.
9. Educate, counsel, and refer for other preventive services
Include a brief written plan, like a checklist, for the patient to get:
A once-in-a-lifetime screening electrocardiogram (ECG), as appropriate
Use these HCPCS codes to file IPPE and ECG screening claims:
G0402
Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment
G0403
Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report
G0404
Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination
G0405
Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination
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
Report a diagnosis code when submitting IPPE claims. We don’t require you to use a specific IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.
When you provide an IPPE 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.
CPT only copyright 2023 American Medical Association. All rights reserved.
No. The IPPE isn’t a routine physical that some patients may get periodically from their physician or other qualified non-physician practitioner (NPP). The IPPE is an introduction to Medicare and covered benefits, and it focuses on health promotion, disease prevention, and detection to help patients stay well. We encourage providers to inform patients about the AWV during their IPPE. The Social Security Act explicitly prohibits Medicare coverage of routine physical exams.
No. The IPPE and AWV don’t include clinical lab tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.
No. We waive the coinsurance, copayment, and Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening electrocardiogram (ECG) (HCPCS codes G0403, G0404, or G0405).
A patient who hasn’t had an IPPE and whose Part B enrollment began in 2023 can get an IPPE in 2024 if it’s within 12 months of the patient’s Part B enrollment effective date.
We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, find your MAC’s website.
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 dressing, feeding, toileting, and grooming; physical ambulation, including balance or fall risks and bathing; and instrumental ADLs (IADLs), including using the phone, 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 the person may be using
2. Establish a current providers and suppliers list
Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.
3. Measure
Measure:
Height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure
Other routine measurements deemed appropriate based on medical and family history
4. Detect any cognitive impairments the patient may have
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. APA’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
Patient’s HRA, health status and 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
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 person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. The Advance Care Planning fact sheet 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.
13. Social Determinants of Health (SDOH) Risk Assessment
Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and ensure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate.
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
Activities of daily living (ADLs), including dressing, feeding, toileting, and grooming; physical ambulation, including balance or fall risks and bathing; and instrumental ADLs (IADLs), including using the phone, 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 the person may be using
3. Update current providers and suppliers list
Include current patient providers and suppliers that regularly provide medical care, including those added because of the first AWV 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 deemed appropriate based on medical and family history
5. Detect any cognitive impairments patients may have
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
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 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 person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. The Advance Care Planning fact sheet 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.
12. Social Determinants of Health (SDOH) Risk Assessment
Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and ensure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate.
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, and how often and how much of each they take
Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists
Coding
Use these HCPCS codes to file AWV claims:
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
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.
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 a previous G0402 (IPPE) billing for the same patient. We deny these claims with messages indicating the patient reached the benefit maximum for the time period.
Medicare telehealth includes HCPCS codes G0438 and G0439.
CPT only copyright 2023 American Medical Association. All rights reserved.
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:
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 a patient’s exam.
Billing
We waive both the Part B ACP coinsurance and deductible when it’s:
Provided on the same day as the covered AWV
Provided by the same provider as the covered AWV
Billed with modifier 33 (Preventive Service)
Billed on the same claim as the AWV
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 ACP 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.
CPT only copyright 2023 American Medical Association. All rights reserved.
SDOH is important in assessing patient histories; in assessing patient risk; and in 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 yours 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:
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 a patient’s exam.
Billing
The implementation date for SDOH Risk Assessment claims is January 1, 2024. We waive both the Part B SDOH Risk Assessment coinsurance and deductible when it’s:
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.
No. The AWV isn’t a routine physical some patients may get periodically from their physician or other qualified NPP. We don’t cover routine physical exams.
No. We waive the coinsurance, copayment, and Part B deductible for the AWV.
We cover an AWV for all patients who’ve had Medicare coverage for longer than 12 months after their first Part B eligibility date and who didn’t have an IPPE or AWV within those past 12 months. We cover only 1 IPPE per patient per lifetime and 1 additional AWV every 12 months after the date of the patient’s last AWV (or IPPE).Check eligibility to find when a patient is eligible for their next preventive service.
No. The IPPE and AWV don’t include clinical lab tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.
Generally, you may provide other medically necessary services on the same date as an AWV. The deductible and coinsurance or copayment applies for these other medically necessary and reasonable services.
You have different options for accessing AWV eligibility information depending on where you practice. Check eligibility to find when a patient is eligible for their next preventive service. Find your MAC’s website if you have specific patient eligibility questions.
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).
CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Early detection saves lives. Encourage patients to get their 
