Medicare AWV (Annual Wellness Visit) & Preventive Services Billing Guidelines

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Annual Wellness Visits: G0402, G0438 & G0439


G0402 – Initial Preventive Physical Examination (IPPE):

  • This code must be billed within the first 12 months of Medicare Part B enrollment.
  • It can be billed only once in a lifetime.
  • It cannot be billed after the first 12 months of Part B coverage.
  • If G0402 has already been billed within the first 12 months of Medicare Part B enrollment, any subsequent wellness visit during the same 12-month period cannot be billed as another preventive wellness visit. In such cases, appropriate office visit CPT codes (99212–99215) may be billed if medically necessary.

G0438 – Initial Annual Wellness Visit:
  • This code must be billed after the first 12 months of Medicare Part B enrollment.
  • It can be billed once in a lifetime.
  • It cannot be billed within the first 12 months of Part B coverage.
  • If G0438 has already been billed, any subsequent wellness visit within the next 12-month eligibility period cannot be billed as another Annual Wellness Visit. In such cases, appropriate office visit CPT codes (99212–99215) may be billed if medically necessary.
  • After completion of 12 months from G0438, the next eligible wellness visit should be billed using G0439.

G0439 – Subsequent Annual Wellness Visit:
  • This code must be billed at least 12 months after G0438.
  • It can be billed once every 12 months thereafter.
  • If G0439 has already been billed, any subsequent wellness visit within the next 12-month eligibility period cannot be billed as another Annual Wellness Visit. In such cases, appropriate office visit CPT codes (99212–99215) may be billed if medically necessary.

Preventive Services CPT Codes: 99381 – 99397

Routine preventive physical exam CPT codes (99381–99397) are typically not covered by Medicare. Instead, Medicare covers:
  • G0402 – Welcome to Medicare Visit (IPPE)
  • G0438 – Initial Annual Wellness Visit
  • G0439 – Subsequent Annual Wellness Visit
  • Problem-oriented office visits (99212–99215) when medically necessary
Note: Medicare uses the “11 full months rule,” meaning the next Annual Wellness Visit (AWV) is eligible after 11 full months have passed from the previous AWV date, not exactly 365 days. For example, if the last AWV date is January 10, 2025 then the next eligible AWV date will be December 1, 2025.

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Days in AR Calculator

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This tool calculates the number of days it takes to receive payment for services.

Please use data from a specific and consistent time period to ensure accurate calculation. For example, if you are using 3 months of data, enter the Total Billed Charges and Total Accounts Receivable for that same period, and set the Number of Days to 90. The Number of Days should vary depending on the time period used for the data.

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Understanding Negative Claim Balance in Account Receivable

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  • In Account Receivable (AR), accurate posting is critical to ensure the claim balance reflects the correct financial position. Even a small error in posting can move the account into a credit (negative balance) or debit (positive balance). Let’s understand this with a simple example.
  • Suppose a claim is submitted for $100.00 and it is processed by insurance and allowed & paid for $20.00 then it should be posted as follows.
    • Allowed - $20.00
    • Paid - $20.00
    • Coinsurance - $0.00
    • Deductible - $0.00
    • Copayment - $0.00
    • Adjustment - $80.00
    • Calculation: $100.00 (Charge Amount) – $20.00 (Paid Amount) – $80.00 (Adjustment Amount) = $0.00
  • With the above posting, the balance amount will become zero. However, if there is any incorrect posting in the adjustment or payment amount, the account may move into either a credit or debit balance. Let's understand this with the following scenarios.
  • Scenario 1: In the above posting example, if the adjustment is incorrectly posted as $90.00 then the claim balance will move into a credit of (-$10.00).
    • Calculation: $100.00 (Charge Amount) – $20.00 (Paid Amount) – $90.00 (Adjustment Amount) = -$10.00 (Credit Balance)
  • Scenario 2: In the above posting example, if adjustment is incorrectly posted as $75.00 then the claim balance will move into a debit of ($5.00).
    • Calculation: $100.00 (Charge Amount) – $20.00 (Paid Amount) – $75.00 (Adjustment Amount) = $5.00 (Debit Balance)
  • If you find any account in credit then always check whether the posting is done correctly or not.
  • The claim may not be always in credit due to incorrect posting. Below are other possible reasons.
  • Duplicate Insurance Payment:
    • The insurance company may accidentally pay the claim twice. In such cases, it is important to verify whether the claim was actually paid twice or if the payment was posted twice in error. If the insurance company truly issued two payments then it is required to send refund back to the insurance carrier.
    • To issue a refund to the insurance company, it is necessary to contact the insurance representative to confirm the appropriate method and address for sending the refund. Sometimes, a refund request is already sent by the insurance and the request includes all the detailed instructions on how and where the refund should be submitted.
  • Excess Patient Payment:
    • Sometimes, a patient may pay more than their actual responsibility, which can also result in a credit balance. In such cases, The excess amount may be applied to other outstanding claims with pending patient responsibility.
    • If no other claims with outstanding balance exists then the amount may be refunded to the patient or can be adjusted with the patient resp of future claims.
  • All of the above activities are typically handled by the Credit Balance (CB) team when a claim balance is in credit. However, in the absence of a CB team, these responsibilities fall under the Account Receivable (AR) team.

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Appeal Process

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  • A claim requires an appeal when it has been processed and denied by the payer and the issue cannot be corrected by simply resubmitting or correcting the claim.
  • The appeals process typically consists of two stages:
            1 - Reconsideration (first-level appeal)
            2 - Appeal (second-level appeal)
  • A second-level appeal should be submitted if the reconsideration (first-level appeal) is upheld.
  • There are 3 modes for submitting an appeal: fax, mail or portal. It is important to confirm the accepted submission modes with the insurance representative and you should give priority to fax and portal modes if it is acceptable as it takes less time to receive by payer.
  • Reconsideration and appeal has a time limit and it is different based on the insurance. So, it needs to be confirmed and submitted within the time limit.
  • When submitting an appeal for any denial, it is necessary to prepare a package that includes at least two documents.
            1 - General Letter or Insurance-Specific Appeal Letter
            2 - Supporting Documents
  • General Letter or Insurance-Specific Appeal Letter:
    • Many insurance companies have specific appeal letters that must be completed and submitted when filing an appeal. The first-level and second-level appeal letters may differ, so it is important to contact the insurance representative to confirm the requirements for both reconsideration and appeal letters. Sometimes, these information are also available on their portal.
    • An appeal letter generally includes the following sections:
      • Patient Information
      • Provider Information
      • Insurance & Claim Information
      • Reason for Submitting Appeal
    • If the insurance company does not provide a specific appeal letter or form, you will need to create a general appeal letter that includes all of the above information.
    • Below is the example of general appeal letter. You may modify the wording as needed or get client approval before using it.


  • Supporting Documents: These should include all supporting documents that strengthen your appeal. They will be reviewed by the insurance company and may help overturn the original decision.
    • Below are the denials and the corresponding supporting documents that can be attached when submitting an appeal.
      • TFL Denial: It requires POTF (Proof of Timely Filing) to be submitted. POTF can be any documents that prove the submission of claim within the timely filing limit of the insurance. The documents must include submission date and below documents can be used as POTF.
        • Clearinghouse Submission Report
        • Payer Acknowledgement / Acceptance Report
        • EDI Acceptance Screenshot
      • Medical Records Required or Insufficient Document Denial: This denial requires submission of the documents that can support the denial CPT.

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    Interview Questions - Part II

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    Waiver Of Liability

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    A waiver of liability can protect either the patient or the healthcare provider from financial risk, depending on who signs it, what it's intended for, and whether it’s initiated by the provider or the insurance company. There are two main types of waiver of liability commonly used in medical billing:

    1. Patient-Signed Waiver of Liability
    2. Provider-Signed Waiver of Liability

    1. Patient-Signed Waiver of Liability:
    • This waiver is similar to an Advance Beneficiary Notice (ABN) but is used for non-Medicare payers.
    • It is a written agreement provided by the healthcare provider to inform the patient that they may be financially responsible if the insurance denies the claim.
    • By signing this waiver, the patient acknowledges and agrees to pay for the service in the event of a denial.

    2. Provider-Signed Waiver of Liability:
    • This is a written agreement initiated by the insurance company and the provider must sign to confirm that the patient will not be billed for the service if the claim is denied.
    • Insurance companies typically request this waiver when the provider submits a final appeal for a denied claim.
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    Hospital Billing Codes

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    Revenue Codes: 
    • These codes describe the type & the location of the service.
    • For example: 0450 - Emergency Room General Services, 0300 – Laboratory General Services, etc.
    • These are 4 digis codes.
    • It is used in locator 42 on UB-04 form.

    Condition Codes:
    • These codes describe specific circumstances or situations of patient's care.
    • For example: 02 - Condition is employment related, 17 - Patient is homeless, etc.
    • These are 2 digits codes.
    • It is used in locators 18-28 on UB-04 form.

    Occurrence Codes:
    • These codes describe specific dates & events that occurred during patient treatment.
    • For example: 01 - Auto Accident Date, 02 - Date of illness or injury, etc.
    • These are 2 digits codes.
    • It is used in locators 31-34 on UB-04 form.

    Occurrence Span Codes:
    • These codes describe the span of the particular service or events provided to the patient.
    • For example: 77 - Hospital stay start date, 78 - Hospital stay end date, etc.
    • These are 2 digits codes.
    • It is used in locators 35-36 on UB-04 form.

    Value Codes:
    • These codes provide additional monetary information related to a patient's care or services.
    • For example: 01 - Patient's age, 18 - Number of covered days, etc.
    • These are 2 digits codes.
    • It is used in locators 39-41 on UB-04 form. 

    TOB (Type Of Bill):
    • TOB helps payers to quickly identify the claim type for processing and reimbursement.
    • These are 4 digits codes and each digit has a specific reason which is very important while submission.
    • 1st digit: It is always 0.
    • 2nd digit: Indicates type of facility. Examples - Hospital, RHC, SNF etc.
    • 3rd digit: Type of care. Examples - Inpatient, outpatient etc.
    • 4th digit: Indicates claim frequency. Examples - Original, adjustment etc.
    • It is used in locator 4 on UB-04 form.

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