Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Timing requirement not met (must be within 12 months of Medicare Part B enrollment)
Very CommonInitial AWV (G0438) must be performed within first 12 months of Medicare Part B enrollment. Claims submitted after this window are denied.
Common Causes
- • Visit scheduled >12 months after Part B effective date
- • Patient delayed scheduling beyond eligibility window
- • Practice unclear on patient's Part B enrollment date
Resolution Strategy
If patient is within 12-month window, provide Medicare Part B enrollment date proof. If outside window, patient not eligible for G0438. Bill appropriate E/M code instead.
2. Previous AWV already billed (lifetime once benefit)
CommonG0438 (Initial AWV) is a one-time benefit. If patient already had initial AWV, subsequent visits should be G0439 (Subsequent AWV).
Common Causes
- • Patient had initial AWV at previous practice
- • Clerical error selecting G0438 instead of G0439
- • Practice not checking AWV history before billing
Resolution Strategy
Correct code to G0439 if patient eligible for subsequent AWV. Verify last AWV date was >12 months ago.
Medical Necessity: ICD-10
Who are you?
Code Details
Medicare Pricing
PFSRVU Breakdown
OPPS Details
Automate Coding
Let OrbDoc AI automatically suggest codes from your clinical notes.
Patient? Check your bill.
Use our free analyzer to understand charges and spot errors.
Analyze My BillAsk OrbDoc AI
Get instant answers about G0438 - pricing, bundling rules, or billing questions.
Ask a QuestionFrequently Asked Questions
CPT G0438 is the billing code for "Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit". It falls under the Procedures/Services category and is used by healthcare providers to bill insurance for this specific service.
Medicare pays approximately $160.44 for CPT G0438 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
The most common denial reason for CPT G0438 is "Timing requirement not met (must be within 12 months of Medicare Part B enrollment)". Initial AWV (G0438) must be performed within first 12 months of Medicare Part B enrollment. Claims submitted after this window are denied. Common causes include: Visit scheduled >12 months after Part B effective date; Patient delayed scheduling beyond eligibility window. Appeal success rate is approximately 10-30%.