Annual Wellness Visits (AWV)
Wellness visits that are planned, complete and worth the slot
The Medicare Annual Wellness Visit is a yearly prevention-planning visit with no patient cost-sharing. We design the visit, the pre-visit work and the outreach campaigns, so each AWV produces a personalized prevention plan and captures the quality and documentation work your contracts depend on.
- Initial AWV G0438
- Subsequent AWV G0439
- Health Risk Assessment
- Personalized prevention plan
Who it's for
Built for the teams that run this program
Primary care practices with Medicare panels
Practices where many eligible patients have not had an AWV this year, or where visits are done but elements are missing.
Practices in value-based contracts
Groups that rely on the AWV to close care gaps and to document chronic conditions accurately once a year.
FQHCs and multi-site groups
Organizations that need a standard AWV template and a shared campaign calendar across sites and staff roles.
Design & launch
How we design and launch it
A visit model that uses clinical staff for the structured work and keeps provider time for decisions.
- 1
Eligibility logic
Rules that sort patients into initial or subsequent AWV, and flag those too soon after an IPPE or a prior AWV.
- 2
Pre-visit planning
Health Risk Assessment sent or completed before the visit, open care gaps listed, and conditions needing reassessment surfaced for the provider.
- 3
Visit template
EHR template with every required element, the cognitive assessment, depression and functional screens, and the written screening schedule.
- 4
Role design
Who completes the HRA review, vitals and screening tools, and what the billing practitioner does and signs.
- 5
Campaign plan
Outreach lists, scripts, scheduling targets and a cadence through the year, with a push early in the year.
Gate: Pilot one site before the campaign scales.
- 6
Training
Staff and provider training on the elements, the add-ons, and what the AWV is not (it is not a head-to-toe physical).
Operations
How the program runs day to day
Campaigns keep the schedule full; the template keeps each visit complete.
AWV campaigns
Who to reach
- Eligible patients with no AWV this year
- New Medicare patients
- Patients with open care gaps
- High-risk patients not seen recently
How we reach them
- Phone, text and portal outreach scripts
- Scheduling at checkout for the next eligible date
- Standing orders for screenings and labs
- Recall lists worked weekly
What we review
- Completion against the eligible panel
- No-shows and reschedules
- Elements missing from completed visits
- Gaps closed at or after the visit
The AWV as a quality and risk-capture touchpoint
The AWV itself is preventive. What it enables is a once-a-year structured look at the whole patient.
Quality
Screenings, immunizations, fall risk, depression screening and functional status are reviewed and ordered, which supports many HEDIS and Star measures.
Accurate documentation
Chronic conditions flagged in pre-visit review can be assessed and documented by the provider. A problem-oriented service on the same day is a separate E/M with its own documentation and modifier.
Documentation & compliance
Documentation and compliance essentials
Medicare fee-for-service rules for CY 2026.
Initial versus subsequent AWV
G0438
- When it applies
- First AWV, for a patient past the first 12 months of Part B who has not had an IPPE or AWV in the past 12 months
- Frequency
- Once per lifetime
G0439
- When it applies
- Every AWV after the initial one
- Frequency
- Once per year, at least 11 full months after the last AWV
Medicare waives the deductible and coinsurance for the AWV.
Required elements
Initial visits establish these; subsequent visits update them.
- Health Risk Assessment covering demographics, self-assessed health, psychosocial and behavioral risks, and activities of daily living.
- Medical and family history, current medications and supplements, and a list of current providers and suppliers.
- Measurements: height, weight, BMI (or waist circumference) and blood pressure.
- Detection of any cognitive impairment, by direct observation with input from the patient, family or caregivers.
- Review of risk factors for depression and of functional ability and safety (initial AWV).
- Review of opioid prescriptions and screening for potential substance use disorders.
- Written screening schedule for the next 5 to 10 years, and a list of risk factors with the interventions recommended.
- Personalized health advice and referrals, such as fall prevention, nutrition, physical activity and tobacco cessation.
Optional elements and add-ons
Advance care planning
Offered at the patient's discretion. When furnished with the AWV (99497, reported with modifier 33), Medicare waives cost-sharing for the ACP.
Social needs screening
CMS added an optional social determinants of health risk assessment to the AWV in 2024 and revisited it in CY 2026 rulemaking. Confirm whether a separately reportable assessment applies this year before building it into the claim.
KPIs we track
What we measure with you
AWV completion rate
Completed AWVs over eligible Medicare patients, by provider and site.
Element completeness
Visits with every required element documented, from internal chart audit.
Campaign conversion
Patients reached, scheduled and seen from each outreach list.
Care gaps closed
Screenings, immunizations and follow-up ordered at the visit and completed after it.
Cognitive and depression screening rate
AWVs with both assessments documented.
Advance care planning rate
Patients offered ACP, and those who chose to complete it.
Baselines and targets are set from your own data at the start of an engagement. We do not promise specific results.
FAQs
Common questions
Is the AWV a physical exam?
No. The AWV is a prevention-planning visit. It does not include a comprehensive physical exam, and Medicare does not cover a routine physical. A medically necessary problem-focused service on the same day is billed separately.
Who can perform the AWV?
A physician or other eligible practitioner, or a team of medical professionals working under a physician's supervision. We design the split of work so clinical staff complete what they are allowed to and the billing practitioner completes the rest.
Does the patient pay anything?
Medicare waives the deductible and coinsurance for the AWV itself. Cost-sharing can apply to separate services provided on the same day, which is why scripting matters.
Related services
Programs that work alongside this one
Practice Transformation & Quality Improvement
HEDIS and Star measures, care gap closure, AWV campaigns and care team redesign.
Learn moreRisk Adjustment & Coding Optimization
CMS-HCC V28 risk capture: prospective review, retrospective audits and provider education.
Learn moreMIPS & Quality Payment Program
Measure selection, data completeness and submission readiness.
Learn moreChronic & Principal Care Management (CCM / PCM)
Care plans, monthly time-based care management and documentation.
Learn more
Ready to simplify the complex?
Book a consultation.
A working conversation about your patients, payers, EHR and staffing, and whether this program fits. Please do not send patient information.