Billing for preventive services in Medicare
A member of ACP's practice management staff outlines how to receive reimbursement for preventive services.
Preventive services are essential for disease prevention and early detection and help improve patients' overall health. Medicare covers multiple types of preventive services, and it is important to distinguish among the requirements for each to ensure that claims are not denied. There are several types of preventive services to know about when considering reimbursement.
Welcome to Medicare visits
The Initial Preventive Physical Examination (IPPE) (G0402) is also known as the “Welcome to Medicare” visit. This service must be provided within 12 months of Medicare Part B enrollment. Any attempt to bill using G0402 after this 12-month deadline will result in an automatic denial. The IPPE is not an annual physical but emphasizes health promotion, disease prevention, and detection. Qualified clinicians must engage with the patient on a comprehensive medical history, including medications, family history, and social history.
Medicare Annual Wellness Visit
After the first 12 months of Medicare Part B enrollment, patients are eligible for an Annual Wellness Visit (AWV). The initial AWV (G0438) is the first wellness visit performed by any clinician for that patient; this code can only be used once per Medicare beneficiary. The subsequent AWV (G0439) has the same content but is assigned a lower payment because it can be completed by updating the previous AWV. The AWV may be performed by any licensed care team member under the supervision of the billing physician.
The IPPE and AWV overlap in screenings provided, but there are differences. Physicians performing an AWV must establish the patient's medical and family history and identify current clinicians who regularly offer medical care. Physicians must also perform a health risk assessment that includes physical function, psychosocial risks, behavioral risk factors, activities of daily living, and the patient's self-assessment of their health status. Another element of the AWV is relevant health counseling, which should be supplemented by providing a personalized preventive plan of services. Similarly to the IPPE, the AWV is not a routine physical.
A physician can also provide advance care planning services during the IPPE or AWV at the patient's discretion. The advance care planning codes are time-based; the CPT base code 99497 should be used for the first 16 to 30 minutes and the CPT code 99498 should be used for each additional 30 minutes. Medicare will waive the Part B co-insurance and deductible for advance care planning when billed alongside the covered IPPE/AWV and modifier-33 is used, which indicates a preventive service.
G2211
Starting in 2024, CMS began reimbursing for G2211, an add-on code that supports comprehensive outpatient services within a longitudinal and continuous patient care relationship. In 2025, CMS expanded the usage of G2211 to be reported alongside modifier -25 when the base E/M code is reported by the same physician on the same day as an AWV, vaccine administration, or any Medicare Part B preventive service.
Standard adult preventive services
For standard adult preventive services, CPT codes are based on the patient's age and whether the patient is new or established. While the exact content of the visit is dependent on the specific patient, these comprehensive preventive medicine services should review medical history, counseling, risk factor reduction interventions, and ordering of laboratory or diagnostic procedures if necessary.
The chart lists the appropriate CPT codes for standard adult preventive services. Note that codes for patients ages 65 years and older are not payable by traditional Medicare but may be covered by certain Medicare Advantage plans (Table).
The type of preventive services offered depends on the patient's age, gender, family history, and other factors. ACP recommends reviewing the U.S. Preventive Services Task Force grade A and B recommendations.
An ACP webinar on billing for preventive services, recorded in March, highlights the importance of screening for preventive services and how to receive proper reimbursement from payers. ACP also offers a broad catalog of Medicare coding- and billing-related resources, including a Coding for Clinicians subscription series that features a learning module to properly report adult preventive medicine visits and a newly updated module to reflect recent changes to G2211. For additional information from CMS, please refer to their page on Medicare wellness visits.
