A Medicare Annual Wellness Visit template walks you through every element CMS requires for G0438 and G0439 (the health risk assessment, medication reconciliation, cognitive and depression screenings, and the written personalized prevention plan) so nothing required for payment gets missed. The AWV has a fixed checklist, and a visit that skips one item doesn't get paid.

Below you'll find a free downloadable AWV template, a breakdown of the three Medicare wellness visit codes, a step-by-step documentation guide, and the three reasons AWV claims most often get denied.

Quick download: Grab the free Medicare Annual Wellness Visit template here.

Key Takeaways

• The AWV is not a physical exam: Medicare doesn't cover routine head-to-toe physicals. The Annual Wellness Visit is a structured health risk assessment and prevention planning session; documenting it like a physical is one of the fastest routes to a denial.
  
  

• The code sequence is fixed: G0402 (Welcome to Medicare) is available only in the first 12 months of Part B. G0438 (initial AWV) is billed once per lifetime, and G0439 (subsequent AWV) every year after. G0439 without a prior G0438 on record gets rejected.
  
  

• Screenings need a tool and a score: "Cognitive screening performed, negative" is exactly what auditors reject. Document the instrument used (Mini-Cog, PHQ-2/PHQ-9) and the result.
  
  

• The prevention plan must be written and given to the patient: A checklist reviewed verbally doesn't satisfy the requirement. The patient has to leave with a written personalized prevention plan, and your note has to say so.
  
  

What Is a Medicare Annual Wellness Visit?

A Medicare Annual Wellness Visit (AWV) is a yearly preventive visit for Medicare Part B patients focused on health risk assessment and prevention planning, not diagnosis or treatment. It's covered at 100% with no copay or deductible, and it produces one core deliverable: a written personalized prevention plan the patient takes home.

This is where most confusion starts. Patients hear "annual visit" and expect a physical. But the AWV involves no hands-on examination beyond basic measurements: blood pressure, weight, and (for the initial visit) height and BMI. Medicare explicitly does not cover a routine annual physical, which is why the visit structure, the patient conversation, and the documentation all need to reflect a planning visit rather than an exam.

The distinction matters clinically too. The AWV is the one visit each year built entirely around screening schedules, cognitive function, fall risk, and advance care planning, the things that get crowded out of problem-focused visits.

G0402 vs. G0438 vs. G0439: Which Code Applies

Medicare uses three codes across a patient's preventive timeline, and eligibility for each depends on enrollment date and visit history, not on how the visit went.

Two rules trip practices up more than any others:

• G0438 always comes first. If a patient has never had an initial AWV billed anywhere (even if they've been on Medicare for a decade), you bill G0438, not G0439. Long-tenured patients don't skip to the subsequent code.
  
  
  

• Eligibility is month-based, not date-based. A patient seen on April 10, 2025 becomes eligible again on April 1, 2026: the first day of the same calendar month the following year. Scheduling on the exact anniversary date isn't required and just delays the visit.
  
  
  

Check the patient's Part B effective date and AWV history before the appointment. Most frequency denials come from codes chosen out of habit instead of eligibility.

What to Include in a Medicare Annual Wellness Visit Template

CMS defines the required elements, and a complete AWV note covers all of them. Our free template is organized around this list:

• Visit type and eligibility: Which AWV is being billed, and whether a prior G0438 or IPPE is on record.
  
  

• Health Risk Assessment (HRA): Demographics, self-reported health status, psychosocial and behavioral risks, and activities of daily living. Completed by the patient or with staff assistance, before or during the visit.
  
  

• Medical and family history: Established at the initial AWV, updated at each subsequent one.
  
  

• Current providers and suppliers: A list of all clinicians and durable medical equipment suppliers involved in the patient's care.
  
  

• Medication reconciliation: Every medication, including OTC and supplements, reviewed and reconciled.
  
  

• Measurements: Blood pressure and weight at every AWV; height and BMI at the initial visit.
  
  

• Cognitive assessment: Screening for cognitive impairment using a validated tool, with the tool and result documented.
  
  

• Depression screening: Typically PHQ-2 stepping to PHQ-9, with the score recorded.
  
  

• Functional ability and safety: Fall risk, hearing, home safety, and ability to perform daily activities.
  
  

• Personalized prevention plan: A written screening schedule for the next 5–10 years, a list of risk factors with interventions, and personalized health advice or referrals, all furnished to the patient.
  
  

The subsequent AWV (G0439) updates these elements rather than establishing them, but the structure is the same. That's the value of a template: the difference between the two visits becomes a matter of which boxes you're refreshing, not which sections you remember to include.

Pro tip: Send the HRA to the patient before the appointment. A patient who completes it in the waiting room or at home turns a 45-minute visit into a 20-minute one, and the answers arrive more accurate than what they'd recall on the spot.

How to Document an AWV Step by Step

1. Confirm eligibility before the patient arrives

Pull the Part B effective date and the AWV billing history. This single check determines the code, and it's the only step that can't be fixed after the fact. If the patient had a G0402 IPPE, confirm at least 12 months have passed.

2. Capture the HRA and history sections completely

The HRA is mandatory for both G0438 and G0439; a claim without it is denied outright. Document that it was completed, by whom, and summarize the findings that feed the prevention plan.

3. Record screenings with tool and score

For cognition, name the instrument (Mini-Cog, MoCA, or MMSE) and the result. For depression, record the PHQ-2 or PHQ-9 score. A named tool with a number survives an audit; a conclusion without one doesn't.

4. Write the prevention plan, and document that the patient received it

This is the deliverable Medicare is paying for. The plan should include a personalized screening checklist (mammography, colorectal, bone density, immunizations), the patient's risk factors with recommended interventions, and any referrals. Then add the line auditors look for: "Written personalized prevention plan provided to patient."

5. Add eligible services in the same encounter

The AWV pairs cleanly with several add-ons:

• Advance care planning (+99497): When performed voluntarily on the same day as an AWV, the patient's deductible and coinsurance are waived. Document the discussion, time spent, and whether forms were completed.

• SDOH risk assessment (G0136): A standardized social determinants screening billable alongside the AWV.

• A problem-focused E/M with modifier -25: If the patient raises an acute issue, you can bill a separate, significant E/M service, but the documentation for each must stand on its own.

Why AWV Claims Get Denied

Three failure modes account for most AWV denials, and all three are preventable at the documentation level.

• Sequence errors: Billing G0439 for a patient with no G0438 on record, or billing G0438 twice. The initial AWV is once per lifetime, across all providers, not just your practice.
  
  

• Timing errors: Billing inside the 12-month window, or within 12 months of a G0402 IPPE. Remember the month-based rule: eligibility reopens the first day of the same calendar month the following year.
  
  

• Missing elements: No documented HRA, screenings without tools or scores, or no evidence the written prevention plan was furnished to the patient. The visit happened; the note just doesn't prove it.
  
  

There's a fourth, subtler failure: documenting the AWV like a physical exam. A note full of system-by-system exam findings and no prevention plan reads to a reviewer like a service Medicare doesn't cover. Keep the note anchored to the AWV's actual elements.

Bottom line: The AWV is one of the few encounters where the documentation checklist is the payment criteria. A template that mirrors the CMS element list turns a denial-prone visit into one of the most reliable claims in primary care.

AWVs Without the Documentation Burden, with Sully.ai

A template solves the structure problem. It doesn't solve the time problem: a thorough AWV covers a dozen required elements, and typing them all into the EHR is a big part of why practices leave these visits unbilled.

This is where an AI medical scribe changes the math. With Sully.ai, the scribe listens to the encounter and drafts the note directly into your AWV template: HRA findings, screening tools and scores, the medication reconciliation, and the prevention plan language, all ready for your review before the patient leaves.

For practices running AWVs at scale, the benefits compound:

• More AWVs completed per day, because documentation stops being the bottleneck.

• Cleaner claims, since the AI Medical Coder checks that the note supports the code before it goes out.

• Every required element captured live, instead of reconstructed at the end of the day.

Sully.ai is built for healthcare from the ground up and meets HIPAA standards for handling protected health information.

Frequently Asked Questions

What is included in a Medicare Annual Wellness Visit?

An AWV includes a health risk assessment, medical and family history, a list of current providers and suppliers, medication reconciliation, blood pressure and weight (plus height and BMI at the initial visit), cognitive and depression screenings, a functional ability and safety assessment, and a written personalized prevention plan furnished to the patient. It does not include a physical examination.

What is the difference between G0438 and G0439?

G0438 is the initial Annual Wellness Visit, billed once per patient lifetime after 12 months of Part B enrollment. G0439 is the subsequent AWV, billed every 12 months thereafter. G0438 establishes the health risk assessment and prevention plan from scratch; G0439 updates them. G0439 cannot be billed without a G0438 on record.

How much does Medicare pay for an Annual Wellness Visit?

Under the 2026 Medicare Physician Fee Schedule, the initial AWV (G0438) reimburses roughly $175 nationally and the subsequent AWV (G0439) roughly $120–$140, varying by locality. Patients pay nothing: the AWV is covered at 100% with no deductible or coinsurance.

Is the Medicare Annual Wellness Visit the same as a physical?

No. Medicare does not cover routine annual physicals. The AWV is a health risk assessment and prevention planning visit with only basic measurements. If a patient wants or needs an exam, that's a separate service, potentially billable as an E/M with modifier -25 if a significant problem is addressed, but never as part of the AWV itself.

How often can a patient have an Annual Wellness Visit?

Once every 12 months, using a month-based rule: the patient becomes eligible on the first day of the same calendar month the following year. A patient seen June 20, 2025 is eligible again June 1, 2026. The initial AWV also can't occur within 12 months of a Welcome to Medicare visit (G0402).

Can advance care planning be billed with an AWV?

Yes. Voluntary advance care planning (99497) performed on the same day as an AWV is billed with the patient's deductible and coinsurance waived. Document the discussion, the time spent, and the patient's voluntary participation.

This template is provided for documentation reference only. Adapt it to your practice's protocols and current clinical guidelines. It does not replace clinical judgment.

This article is for general informational purposes and is not legal or medical advice. Confirm that any form you use meets applicable regulations, including HIPAA, and consult your compliance team before deploying it.