What CPT codes should I use for an annual physical exam?

For new patients, use 99385-99387 based on age (99385 for 18-39, 99386 for 40-64, 99387 for 65+). For established patients, use 99395-99397 with the same age ranges. Medicare patients should use G0438 for Initial AWV or G0439 for Subsequent AWV instead.

Can I bill a separate E/M code on the same day as preventive visit?

Yes, if you address a significant, separately identifiable problem beyond preventive care. Append modifier 25 to the problem-focused E/M code (99212-99215). Document the problem separately and ensure medical necessity supports the additional service.

What ICD-10 codes are appropriate for annual physical?

Use Z00.00 for general adult exam without abnormal findings, or Z00.01 with abnormal findings. Add secondary diagnoses for any chronic conditions reviewed. For Medicare AWV, use Z00.00 as primary with chronic condition codes as secondary.

How often can Medicare patients receive an Annual Wellness Visit?

Medicare covers one AWV every 12 months. The Initial AWV (G0438) is available starting 12 months after Part B effective date. Subsequent AWV (G0439) is available annually thereafter. This is separate from the one-time Welcome to Medicare visit (G0402).

What screening tests should be documented for annual physical?

Document age and sex-appropriate USPSTF screenings including blood pressure, BMI, diabetes screening (if risk factors), lipid panel, colorectal cancer screening (45-75), breast cancer screening (women 50-74), cervical cancer screening (women 21-65), lung cancer screening (if smoking history), and depression screening.

Annual Physical Exam Template - Free Preventive Care Template

Primary Care — Annual Physical Exam Template

Primary Care Internal Medicine Updated: 11/7/2025

The Adult Annual Physical Exam Template is designed for family medicine and internal medicine providers conducting preventive care visits for adult patients. This comprehensive template follows evidence-based screening guidelines from USPSTF and includes all required elements for Medicare Annual Wellness Visits and commercial insurance preventive care codes (99385-99387 for new patients, 99395-99397 for established patients). The template systematically documents health risk assessment, review of systems, age-appropriate screening tests, immunization status, lifestyle counseling, and preventive care recommendations. Sections include comprehensive health history review, complete physical examination, assessment of cardiovascular risk factors, cancer screening status, mental health screening, fall risk assessment for elderly patients, advance directive discussion, and personalized prevention plan. This template ensures thorough documentation that maximizes quality metrics, supports value-based care initiatives, and provides continuity for annual health maintenance tracking. Ideal for primary care practices focused on preventive medicine and population health management.

Chief Complaint

Annual exam/preventive care.

HPI

Overall health update, interval concerns, chronic condition review, medication adherence/effects.

Screening & Prevention

Immunizations, cancer screening (age/sex appropriate), CV risk, depression/anxiety, fall risk, alcohol/tobacco.

ROS

General, HEENT, CV, Resp, GI, GU, MSK, Skin, Neuro, Psych, Endo, Heme/Allergy.

Physical Exam

Vitals with BMI, General, HEENT, Neck/Thyroid, CV, Resp, Abdomen, GU (as indicated), MSK, Neuro, Skin.

Assessment & Plan

1) Preventive care: counseling, vaccines, age-appropriate screening orders.
2) Chronic conditions: status, labs, medication adjustments.
3) Lifestyle: diet, exercise, sleep, substance counseling.
4) Follow-up interval.

Patient Instructions

Written instructions provided; portal follow-up for results.

Primary Care — Annual Physical Exam Template

Template

Chief Complaint

HPI

Screening & Prevention

ROS

Physical Exam

Assessment & Plan

Patient Instructions

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