Reimbursement
$160.32
Threshold
N/A
2026 Status
Active
What is CPT Code G0438?
CPT G0438 is defined as: Initial Annual Wellness Visit; includes a personalized prevention plan of service (PPPS), first visit. This visit is for beneficiaries who have been enrolled in Medicare Part B for at least 12 months and have not previously received an AWV.
This code is primarily used for Preventive services. It falls under the category of Preventive Services and is valid for the 2026 calendar year according to the CMS Physician Fee Schedule.
2026 RVU Components
Relative Value Units (Non-Facility)
Work RVU
2.6
Physician Effort
PE (Non-Fac)
2.1
Practice Expense
Malpractice
0.1
Risk Factor
Total RVU
4.8
Note: [(Work RVU * Work GPCI) + (PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor
2026 CMS Policy Intelligence
cost sharing waiver
No deductible or coinsurance for the patient, ensuring zero-cost access to preventive planning.
acp integration
Advance Care Planning (99497) is also waived from cost-sharing when performed with G0438.
relationship to ippe
If the 'Welcome to Medicare' (G0402) window is missed (first 12 months), G0438 becomes the entry point for Medicare wellness.
Administrative Framework
Place of Service
NCCI Exclusions
Key Modifiers
Operational Requirements
minimum time
Procedure-based (Cognitive assessment)
staff type
MD, DO, NP, PA, or medical professional under direct supervision.
frequency
Once per lifetime.
add on codes
99497 (Advance Care Planning), 99212-99215 (with Modifier 25)
components
HRA, family history, list of current providers, screening schedule, cognitive impairment screening, depression screening.
Compliance Checklist
Audit Defense
No specific audit defense elements defined.
Common Clinical Scenarios
CMS Eligibility: N/A (Preventive service).. Benefit available after 12 months of Part B enrollment.
Target Specialties & Utilization
Typical Clinical Indications (ICD-10)
Billing Differentiation
VS G0439
G0438 is Initial; G0439 is for all Subsequent annual years.
VS G0402
G0402 is only for the first 12 months of Medicare; G0438 starts after 12 months.
Frequently Asked Questions
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