The Ultimate Guide to Understanding and Getting Paid for Preventive Services



In 2020, national healthcare expenditures reached $4.1 trillion in the United States, growing nearly 10%. Health spending accounted for close to 20% of the nation’s GDP. Driving much of this spending: chronic illnesses. Traditionally, practitioners have focused on reactive medicine and treated chronic diseases after their onset. However, a dramatic shift is underway as practitioners recognize that an effective way to mitigate chronic diseases and reduce the costliness of treatments is through preventive services.

As practitioners in healthcare organizations across the country work to provide timely, appropriate preventive care to their patients that maximizes its value for improving health and wellness, they must also understand the ins and outs of the associated reimbursement for those important services. A thorough dive into the concept of preventive services, how they’re determined, and their importance as well as their scheduling, billing, and coding will help practitioners ensure positive impacts on patients’ long-term health and that no revenue for these services is left on the table.

Chapter 1: Overview of Preventive Services


What Are Preventive Services and Why Are They Important?

Defining Preventive Care defines preventive services as “Routine healthcare that includes screenings, checkups, and patient counseling to prevent illnesses, disease, or other health problems.” Healthcare providers, insurers, and patients often view preventive services as long-term investments in people’s health. The earlier chronic disease indicators are caught and addressed, the healthier and longer patients may live. For example, the provision of preventive services that target cardiovascular disease alone has the potential to save tens of thousands of lives each year.

Improving Patient Wellness and Preventive Education

The most effective way to keep patients healthier for longer is to prevent the onset or further progression of chronic disease. For example, obesity is often a catalyst for other chronic conditions. However, patients who can decrease their body mass index through lifestyle changes — like increasing their physical activity or making healthier food choices — can often lower their risk for chronic disease significantly. During regularly scheduled preventive services, patients can learn about their chronic disease risk factors, how these factors may negatively impact their future health, and how they can course correct to live a longer, healthier life.

Helping to Decrease Overall Healthcare Spending

Keeping people healthy is not only best for the patient’s wellbeing, but it is also more cost-effective than treating the symptoms of an illness that has already developed. Thus, a key strategy to reducing the economic strain of chronic illness is prevention.

For example, according to the American Journal of Managed Care, patients who took part in Medicare’s annual wellness visits (AWV) experienced a nearly 6% reduction in total healthcare costs over the following 11-month period. With more than 60 million Medicare beneficiaries, organizations that make preventive services an important part of their care can potentially deliver substantial cost savings to patients and achieve significant savings of their own that will enhance the amount of money organizations can keep from their value-based care arrangements.

Covering and Reimbursing for Preventive Services

One of the most significant results of the Affordable Care Act (ACA), enacted in March 2010, was increasing access to preventive services while mitigating rising out-of-pocket costs. When provided by in-network practitioners, preventive services typically receive 100% coverage and at no expense to the patient. Through annual wellness visits, Medicare embraced preventive care cost savings early on. The AWV provides an opportunity for practitioners to connect with patients, evaluate chronic disease risk factors, and create an ongoing preventive screening plan. As of 2022, the average reimbursement for an AWV is between $132 and $170, thus illustrating how organizations promote patient wellness while simultaneously generating recurring revenue. Adding advance care, depression, alcohol, obesity, and other appropriate screenings and interventions to the AWV can increase this reimbursement to more than $300 per visit while providing patients with even more helpful services.

Increasing Revenue and Decreasing Risk

Increasing Revenue and Decreasing Risk

Alternative payment models — such as the merit-based incentive payment system, pay-for-performance, or other advanced payment models — can pose risks for practitioners when unhealthy patients contribute to higher expenses that then lead to lower overall reimbursement. However, if practitioners are meeting specific metrics for patient health and satisfaction and the quality of care provided, these payment models reward practitioners beyond typical fee-for-service reimbursement. Payers are interested in making money, and the best way for them to do so is with healthier patients who require fewer covered (i.e., reimbursable) services.



What to Know About the Preventive Services Task Force

How do practitioners and insurers know what screenings and treatments are considered preventive services? The U.S. Preventive Services Task Force (USPSTF), created in 1984, exerts significant influence by helping to recommend and determine the most beneficial and effective clinical preventive services.

Guided by its goal to positively impact the health of all Americans, USPSTF reviews and updates existing clinical preventive service guidelines and evaluates new preventive service recommendations. As a result of USPSTF’s diligence, practitioners have access to the most reliable and current clinical prevention tactics available. Note: To access the Preventive Services Task Force list of published recommendations, click here.

Following are six elements of USPSTF that describe how it conducts its critically important work.


  1. Preventive Services Task Force is Composed of a Panel of Volunteers

    The Preventive Services Task Force is composed of 16 nationally recognized expert volunteers who specialize in a clinical field of practice. The panel’s main focus is to make evidence-based preventive service recommendations based on existing, peer-reviewed evidence.

  2. Each Recommendation is Given a Letter Grade

    The USPSTF assigns a letter grade of A, B, C, or D, or an “I statement” to its recommendations. The letter grade is given based on the strength of the evidence supporting the recommendation and takes into consideration the balance between risks and harms for specific preventive service. Since some recommended services can be listed in multiple grade categories, practitioners should review the recommendations.

    The definitions for USPSTF’s grades are summarized as follows:
    1. Grade A: Services that receive the A grade are highly recommended by USPSTF because these services are believed to have a substantial net benefit and therefore, practitioners should offer them. Examples include cervical cancer screening, colorectal cancer screenings, high blood pressure screenings, and tobacco cessation interventions.
    2. Grade B: A level B grade means that the service is highly recommended because there is high certainty that the net benefit of the service is moderate, or there is moderate certainty that the benefits of the service will be moderate to substantial. Recommendations include depression screening, genetic counseling and testing, behavioral interventions for weight loss and obesity prevention, osteoporosis screenings, and skin cancer prevention behavioral counseling.
    3. Grade C: Services in this category are recommended by USPSTF on a selective basis, which means that practitioners should use their professional judgment to determine the benefit of these services to the patient based on individual circumstances. Grade C recommendations include abdominal aortic aneurysm screening, prostate cancer screening, statin use for the primary prevention of cardiovascular disease in adults, and aspirin use to prevent cardiovascular disease and colorectal cancer.
    4. Grade D: USPSTF recommends against the provision of grade D services as they have been shown to have no net benefit or the harm of the services outweighs the benefits. Some examples of grade D services: hormone therapy in postmenopausal women as a primary prevention of chronic conditions, thyroid cancer screening, and vitamin supplementation to prevent cancer and cardiovascular disease.
    5. I Statement: A service is designated as an I Statement if there is insufficient evidence demonstrating that the benefits of the service outweigh the potential harms or if the full extent of benefits versus harms cannot be determined. Some I statement service examples include atrial fibrillation screening with electrocardiography and cardiovascular risk assessment with nontraditional risk factors.


  3. Preventive Services Task Force Makes Recommendations About Preventive Services

    USPSTF’s recommendations are meant to help prevent the onset, spread, or the complications associated with specific diseases. To accomplish this, the task force makes three types of preventive services recommendations.

Screening Tests:

A screening test can detect potential health issues or diseases in people without symptoms, resulting in early detection. With the results of screening tests, patients can make lifestyle changes to help prevent disease onset or progression. Examples include depression screening and high blood pressure screening.

Preventive Medications:

USPSTF looks closely at medications that can help prevent disease progression or exacerbation. Examples include aspirin use to prevent cardiovascular disease and statin use for the primary prevention of cardiovascular disease.


When the task force recommends counseling, the main goal is to encourage behavioral changes in patients who are on the path to developing diseases based on their lifestyle choices. Examples include weight loss to prevent obesityrelated morbidity and mortality and tobacco cessation.

  1. Cost is Not Considered in Preventive Services Recommendations

    With preventive health services, the cost of prevention is almost always more economical than the cost of disease treatment. For this reason, USPSTF does not consider the cost of preventive services under evaluation. Although USPSTF has authority to review the cost-effectiveness of services under consideration, it chooses not to so as to keep its focus centered on clinical effectiveness.

  2. Anyone Can Nominate a Topic to the Preventive Services Task Force

    USPSTF recognizes that preventing chronic disease and illness is a team effort among practitioners, patients, payers, and all other vested parties. Thus, any individual or organization can propose a subject matter for the USPSTF to investigate. The task force reviews all evidence about a selected topic, including peer-reviewed scientific studies. For the subject to become a recommendation, the preventive service must be proven effective, and benefits must outweigh the potential for harm. Find out more about nominating a topic for Preventive Services Task Force review here.

  3. Preventive Services Task Force Recommendations Impact Insurance Coverage

    In its aim to improve coverage of and access to preventive care, the ACA uses USPSTF grading to determine health plan coverage. For example:
    1. Under the ACA, non-grandfathered group health plans and health insurance issuers offering non grandfathered group or individual health insurance coverage must provide coverage of items or services with an A or B recommendation rating from the USPSTF.
    2. For Medicare coverage, USPSTF services with a grade A or B must be covered without cost sharing if the HHS secretary determines they are reasonable and necessary for the prevention or early detection of an illness or disability and appropriate for individuals entitled to benefits under Medicare part A or enrolled under Medicare part B preventive care recommendations.
    3. For traditional Medicaid plans, states that cover all USPSTF grade A or B recommended preventive services without cost-sharing receive a 1 percentage point increase in the federal medical assistance percentage for those services.

Chapter 2: Delivering Preventive Services


A Guide for Physicians Offering Preventive Screenings

Despite the effectiveness of preventive care, many clinicians are still struggling to deliver this relatively inexpensive solution. Why? Some believe that payers are over-incentivizing reactive care, rewarding care volume (i.e., fee-forservice) and thus making the provision of preventive services difficult. Others say that patients aren’t always aware of their eligibility to receive such care and often at no cost. Another reason put forth is that the overabundance of chronically ill people who seek treatment makes it difficult for practitioners to flip the healthcare paradigm to a preventive care model. Most likely, all the above factor into the underutilization of preventive services. In fact, the Centers for Disease Control and Prevention (CDC) supports this notion, citing a lack in implementation on the behalf of practitioners.

Although preventive care is encouraged by government policy and insurance providers, there are many challenges when it comes to implementing a preventive screening program in a traditional medical practice. The following are several common hurdles:

Helping All Patients Access Preventive Screenings

Although the provision of preventive services saves lives, access to that care is still a concern and barrier for many Americans. The U.S. healthcare system is relatively good at providing preventive care to younger populations, but their elderly counterparts — who are some of the most vulnerable patients — are often unaware that they should be receiving preventive screenings. The National Council on Aging reports that nearly 80% of older Americans have at least one chronic disease, and of those people, 77% are battling at least two chronic diseases.

Furthermore, income and education levels play a crucial role in whether patients receive preventive services. Of American adults ages 50 to 74 years and making less than $25,000 annually, only half will receive a colorectal cancer screening. This figure is significant because colorectal cancer is not only difficult to treat, but it can cost upward of $50,000 to battle. However, when this disease is caught in its earliest stages, the likelihood for positive outcomes increases and associated treatment costs are considerably lower.

Eligibility requirements determine what preventive services are accessible through a patient’s insurance plan. Every health insurance provider is guided by different recommendations that inform eligibility requirements. Furthermore, variation exists among different coverage plans — even within the same insurance provider. Complicating matters 9 The Ultimate Guide to Understanding and Getting Paid for Preventive Services further is the fact that these policies can and often change regularly. As a result, patient eligibility must be verified with each service so that patients don’t miss opportunities for screenings and so that providing organizations don’t unintentionally perform preventive screenings for which they will not be reimbursed.

Assessing the needs and eligibility of each patient manually is extremely difficult and costly. Technology platforms that automatically compare the individual health history of a patient against available preventive services and insurance coverage eligibility go a long way to streamlining the process. Most offer accessible reports for medical providers, which may increase the likelihood that preventive health screenings occur in a cost-effective and billable manner.

Increasing Efficiency and Patient Involvement

Educating patients is an essential step in the delivery of preventive care, with any lack of understanding concerning the content of preventive care and its services potentially jeopardizing patient follow-through. Thus, clinicians must take time to explain basic and more complex medical concepts (i.e., jargon) so that their patients better understand the services they are receiving and the health goals those services are intended to help them achieve.

Even when patients understand the importance of regular preventive screening, they often rely on their healthcare providers to alert them to what needs to be done and when they should do it. As a result, many providers depend on patient-completed forms and questionnaires to identify available preventive screening options. But the busy medical practice environment makes the one-on-one time needed for completing these forms difficult or even impossible. The time needed to evaluate patients’ screening needs increases significantly if an organization relies on handwritten forms.

Increasing Efficiency and Patient InvolvementAllowing patients to complete forms or assessments in a digital environment — even prior to their office visit — increases efficiency. Digital forms can be integrated into and with other medical software, which cuts back on administrative processing time, decreases the likelihood of missed information, and reduces the risk of human data entry errors.

Ensuring Organizations Can Be Reimbursed

One of the most time-intensive and complicated tasks for practice administrators is coding and billing, especially for preventive services. Through incentive programs like the merit-based incentive payment system (MIPS), quality healthcare practices are encouraged. But maintaining compliance through the program-specific reporting often consumes more resources and ends up costing providers more than the incentives are worth.

The guidelines surrounding Medicare’s annual wellness visits are notorious for their complexity, but compliance with them is critical. Initial reimbursement can be rescinded if a providing organization is deemed non-compliant during an audit. Healthcare organizations may be using extra resources to complete the reporting and billing process for these visits or even missing out on available revenue altogether. In addition to explaining preventive services to patients, practitioners should be sure that Medicare patients don’t confuse the AWV with an annual physical exam as such confusion can prove costly to both parties.

To help ensure that the potential revenue of preventive screenings is worthwhile, providing organizations should invest in a technological resource that can reduce the administrative workload and better ensure ongoing compliance with reporting and billing. Such tools can assess patients, verify eligibility and program compliance, and manage claims, all of which go a long way toward patients receiving the highest quality care while organizations capture revenue — and often recurring revenue at that.



Advance Care Planning as a Medicare Service

Advance care planning (ACP) can be a difficult subject to broach with patients. Yet, it is extremely important because it enables them to make informed decisions about the healthcare they want to receive as they reach the final stages of their lives. Let’s take a closer look at ACP.

Why Are Advance Care Planning Services Important?

ACP services give patients an opportunity to share their preferences with their provider and loved ones about the care they wish to receive when they are no longer able to express their preferences themselves. This includes selecting a healthcare proxy who can make decisions on the patient’s behalf should they become incapacitated. ACP services may even lower the cost of healthcare in general as they can avoid expensive life-prolonging therapies that a patient does not want to receive.

ACP and Advance Directives

For several years now, Medicare has been reimbursing qualified healthcare professionals for ACP services provided to Medicare-eligible patients, both during the provision of the annual wellness visit and as a standalone visit. Although the ACP discussion is voluntary and can be conducted anytime, if the service is performed during the patient’s AWV, the patient incurs no costs. However, if ACP services are performed outside of the AWV visit, the patient will likely be expected to cover any copay, coinsurance, and deductible.

Unlike the AWV, the number of ACP visits per patient is not limited annually. As a patient’s health needs change, updating their advance directives to reflect those changes is prudent.

Advance Care Planning How-To Details

Since primary care providers (PCPs) and their patients are often more connected than patients are with their specialists, PCPs are uniquely situated to initiate ACP discussions. Conversations about advance care planning should take place in person and include the following:

Advance Care Planning How-To Details

  • An honest discussion about future decisions that may potentially arise based on the patient’s individual health history.

  • Information on how to let loved ones and other healthcare professionals know the patient’s specific end-of-life healthcare preferences.

  • Designation of a healthcare proxy that will follow through with the patient’s wishes.

  • Assistance in completing advance directive forms.

During the advance care planning visit, thorough documentation concerning the patient’s advance directives and end-of-life wishes should be completed. This documentation should contain actionable orders that can be easily understood by family and healthcare professionals so that the patient’s wishes can be accurately interpreted and followed.

Since the billing and coding guidelines surrounding advance care planning are complex, many providers may be having ACP conversations with their patients but missing out on a reimbursement opportunity. Scheduling and time constraints are just two of the challenges that can prevent providers from directly scheduling ACP appointments. Often, ACP appointments require more than 15 minutes, which makes impromptu ACP conversations difficult and the required documentation even more daunting.

Providers can overcome these hurdles by changing workflows and providing more patient education about advance care planning services before scheduling the visit. Patients who receive educational materials in advance of their appointment are better able to discuss sensitive issues and prepare their plan before the appointment, which can save time. Medical software with an ACP component can also play a valuable role in tackling the logistics of providing and documenting ACP services by helping ensure each visit is complete and completed properly and by helping eliminate human error in meeting all the requirements.

Practice Revenue from Advance Care Planning

According to a recent Medscape report, less than 3% of qualifying medical providers are conducting and billing for ACP services. When performed and documented correctly, ACP can be billed in addition to an AWV or in addition to other visits, such as evaluation and management services (E/M services). As of 2022, the two primary ACP CPT codes are CPT 99497 and CPT 99498 and pay the provider around $86 for the first 30 minutes of face-to-face time and another ~$75 for each additional 30 minutes. Remember: advance care planning can be updated and billed as many times as necessary to ensure a current reflection of the patient’s health and advance directive wishes.



Don’t Let Depression Remain Silent Among Your Patients

Now let’s focus on one particular — and particularly important — preventive service: depression screening.

Depression can be a silent illness. Individuals often don’t realize that the symptoms they are experiencing — such as changes in sleeping habits, weight gain, unexpected weight loss, back pain, or headaches — are common indicators of depression. Since the symptoms of depression can vary greatly from patient to patient, people often visit their PCP without realizing physical ailments may be caused by a psychological condition. Thus, PCPs are well-positioned to be the first to recognize and diagnose depression in their patients.

Older Americans Are Experiencing Depression at Alarming Rates

According to the CDC, 15%-20% of the U.S. population aged 65 years and over has experienced depression at least once in their lifetime. Compounding the issue of depression in older Americans is chronic illness. When chronic illness and depression co-exist, healthcare costs sharply increase for an already vulnerable population. Older adults face changing life circumstances that can lead to depression, such as the passing of a spouse or partner, losing their independence due to physical decline, or the end of a rewarding career. For PCPs, depression screenings are critical in this demographic so that potential mental health issues can be identified early and successfully treated.

According to the American Psychiatric Association, PCPs are conducting depression screenings for less than 5% of adults. Clearly, depression is severely underdiagnosed and undertreated in older populations.

Implementing Depression Screening in Your Organization

Fortunately, USPSTF and Medicare have identified the benefit of depression screenings, and as such, Medicare covers a co-pay waived annual depression screening for all beneficiaries. Many private insurers have also started covering these screenings. Medicare has also added annual depression screenings to its MACRA/MIPS program, which means that Medicare payment modifiers could be increased through the implementation of depression screenings.

Screening for depression in a primary care setting should be conducted using a validated instrument and can be billed as a standalone service. Depression screening is considered ‘bundled’ within a welcome to Medicare physical (G0402) or initial annual wellness visit (G0438) but can be billed concurrently with a subsequent AWV (G0439). It’s not always easy to add a new process to established clinical workflows, bit implementing comprehensive wellness software can help automate these processes for depression and other behavioral health screenings.


Chapter 3: Coding and Billing Preventive Services


Top Things to Know About the Preventive Services Medicare Covers

For practices seeking to expand their offerings, the following information is essential for understanding the preventive services Medicare covers.

Breakdown of Preventive Services Medicare Covers

Per Medicare guidelines, practitioners should work with their Medicare patients to determine whether these patients should receive the preventive services and screenings listed below. Most of these services are reimbursable to the rendering practitioner and usually fully covered by Medicare with no out-of-pocket expense to the patient.

They can be broken down as follows:

Assessments and Counseling

  • Alcohol Misuse Screening: Medicare covers one screening annually and up to four brief, face-to-face counseling sessions per year.

  • Depression Screening: Covered once annually by Medicare.

  • Obesity Screening and Counseling: Intensive behavioral therapy is covered for patients with a body mass index of 30 or more.

  • Behavioral Therapy for Cardiovascular Disease: A risk reduction visit is covered once annually by Medicare.

  • Smoking and Tobacco Use Cessation Counseling: Medicare covers up to eight face-to-face visits every 12-month period.

  • Low dose lung cancer screenings (LDCT) counseling to determine if LDCT imaging should be ordered

Clinical Procedures and Imaging

  • Abdominal Aortic Aneurysm Screening: Covered by Medicare once in a lifetime.

  • Bone Mass Measurements: Covered by Medicare for at-risk individuals once every 24 months.

  • Lung Cancer Screening: A low dose computed tomography (LDCT) scan is covered once every 12 months for patients meeting predefined criteria.

Laboratory Diagnostics

  • Cardiovascular Disease Screening: Covered once every five years and includes tests for cholesterol, lipid, and triglyceride levels.

  • Diabetes Screening: Medicare covers up to two screenings per year for at-risk patients.

  • Prostate Cancer Screening: All men over the age of 50 are covered once every 12 months.


  • Flu Vaccine: Covered once each flu season.

  • Pneumococcal Shots: Medicare covers the initial vaccine, and the second shot is covered 11 months after the first vaccine is given.

  • Hepatitis B Shots: Patients with medium to high risk for Hepatitis B are covered.

Role of the Medicare Annual Wellness Visit

As mentioned earlier, the Medicare annual wellness visit (AWV) is an annual appointment during which a patient meets with a clinical staff member to develop or update a personalized prevention plan. This plan is based on a patient’s current health and risk factors, with the goal of preventing disease. Not only does the AWV offer opportunities for the provision of preventive services, but it also allows for the creation of a future schedule of preventive services.

Coverage of Medicare Preventive Services

Medicare Part B covers many preventive services in full, meaning Medicare beneficiaries will not incur out-of-pocket expenses (co-payment or deductible) when they receive the services. Fully covered preventive services include those listed above as well as diabetes screening (up to twice per year for those patients at high risk of diabetes) and hepatitis C screening test (for those patients at high risk). Some preventive services that are likely to require cost-sharing by the beneficiary include a diagnostic mammogram, digital rectal exam for prostate cancer, and glaucoma test.

If patients seek treatment from providers who do not accept the preventive services assignment and/or if they are enrolled in a Medicare health plan or have other insurance, they may pay more out of pocket. Patients will also pay more if they exceed the covered frequency of a preventive service.

Reimbursement for Preventive Services from Medicare

It is worth noting again the financial value for providing organizations that offer the Medicare AWV. As of 2022, practices receive around $170 per initial AWV and $133 per subsequent AWV. When the necessary preventive services are provided at the same time as the AWV, that number increases.

Even when looking at the frequency of eligibility conservatively, Medicare patients who receive a full suite of preventive services could drive up practice revenue by more than $360 annually per patient. If 50 patients receive the full suite, practices could see $18,000 in annual reimbursement. In addition, with many patients, these services can be provided during just one AWV.

Below is a breakdown of the 2022 average reimbursement for a few preventive services commonly performed with the Medicare AWV, per the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule:


Advance care planning


Annual depression screening


Cardiovascular risk counseling


Obesity counseling

Note: Figures are rounded to nearest dollar amount based on national averages.


Avoiding Denials for Preventive Services

To verify patient eligibility for preventive services, practices must determine the last date that their patients received such services. Practices have two options for verification of this information:

  • Automated verification via the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System, also known as HETS. To avoid purchasing costly tools needed to meet access requirements, many practices work with a vendor that supports electronic eligibility transactions and office automation.
  • Manual verification, which is typically completed via phone call, clearinghouse, or Medicare administrative contractor (MAC) portal but is more time-consuming than automated verification.

Process for Preventive Services to Be Chosen as Medicare Benefits

Due to its regulatory and statutory authority, CMS can add coverage through the National Coverage Determination process if the service meets the following criteria:

  1. Reasonable and necessary for the prevention or early detection of illness or disability;
  2. Recommended with a grade of A or B by the U.S. Preventive Services Task Force; and
  3. Appropriate for individuals entitled to benefits under Part A or enrolled under Medicare Part B.

Private insurers typically follow Medicare’s lead when new services are added. In fact, private payers are legally required to cover many services that USPSTF deems beneficial.

Helping Patients Stay on Track

Helping Patients Stay on Track

Keeping track of what services need to be scheduled can be daunting for patients, especially when the timing of one preventive service is different than another (e.g., monthly rather than annually).

Technological tools can provide electronic reminders, and Medicare’s downloadable “Are You Up-To-Date on Your Preventive Services?” checklist is a helpful resource for patients.

List of ACA Preventive Services and Their CPT & HCPCS Codes

Background on ACA and Preventive Services

When the Affordable Care Act took effect in 2010, it expanded access to preventive care for millions of Americans by mandating that all non-grandfathered health plans cover preventive services for their members as long as those services are provided at the requisite time by an in-network practitioner. Initially, some payers were concerned about the financial impacts to their business. Ultimately, the significant cost savings for insurers and the entire healthcare system has encouraged them to come around and recognize the importance of preventive services for the American public.

What Preventive Services Are Covered Under the ACA?

Following are ACA preventive services, corresponding current procedural terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes and descriptions, as well as patient eligibility. Since services may be added by USPSTF as it continues to review the latest medical research, this list can change.

Abdominal Aortic Aneurysm Screening

  • HCPCS G0389 — Ultrasound b-scan and/or real time with image documentation; for abdominal aortic aneurysm (aaa) screening

  • Eligibility: Men aged 65 to 75 who previously or currently smoke. This screening is covered once per lifetime.

Alcohol Misuse Screening and Counseling

  • HCPCS G0442 — Annual alcohol misuse screening, 15 minutes

  • HCPCS G0443 — Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

  • Eligibility: All patients are eligible for an annual screening, with four additional brief face-face counseling sessions per year for patients who screen positive for alcohol misuse.

Aspirin Use

  • HCPCS G8598 — Aspirin or another antiplatelet therapy used

  • Eligibility: Aspirin is used in high cardiovascular risk adults aged 50 to 59 to prevent cardiovascular disease and colorectal cancer.

Blood Pressure Screening, Cardiovascular Disease Screening, Cholesterol Screening and Statin Preventive Medications

  • CPT 80061 — Lipid panel (must include CPT 82465 cholesterol, serum total; CPT 83718 lipoprotein, direct measurement, high density cholesterol; and CPT 84478 triglycerides)

  • Eligibility: Adults of higher cardiovascular risk. Medicare specifically covers a cholesterol screening once every 5 years and, in addition to cholesterol screening, the services also include testing for lipid and triglyceride levels. All patients are eligible to receive blood pressure screenings.

Colorectal Cancer Screening

A list of CPT and HCPCS codes with descriptions and patient qualifiers can be found here.

  • Eligibility: Specifically, for Medicare patients, colorectal cancer screening can be performed in a few different ways with each having its own qualifiers based on risk.

  • For screenings using the multitarget stool DNA test, patients must be between the ages of 50 and 85, be asymptomatic, and at an average risk of developing colorectal cancer. Patients are eligible for this screening once every three years.

  • Screening Flexible Sigmoidoscopy: Once every 48 months

  • Colonoscopy: Once ever 10 years or 48 months after a previous sigmoidoscopy. For high-risk patients, colonoscopy is covered once every 24 months.

  • Fecal Occult Blood Tests (FOBTs): Once every 12 months

  • Screening Barium Enemas: Once every 12 months

Depression Screening

  • HCPCS G0444 — Annual depression screening, 15 minutes

  • Eligibility: ACA mandated that insurance plans must cover a screening for depression. For Medicare beneficiaries, depression screening is covered once annually.

Diabetes Screening

  • CPT 82947 — Glucose; quantitative, blood (except reagent strip)

  • CPT 82950 — Glucose; post glucose dose (includes glucose)

  • CPT 82951 — Glucose; tolerance test (GTT), 3 specimens (includes glucose)

  • Eligibility: This screening is for patients with certain diabetes risk factors or a diagnosis of pre-diabetes. Patients with pre-diabetes are eligible for a screening once every 6 months and once every 12 months for everyone else.

Falls Prevention

  • HCPCS G0402/G0438/G0439 as part of Medicare’s initial or AWV.

  • Eligibility: ACA mandated no-cost coverage for adults 65 years old and over who live in a community setting. Fall prevention is often discussed during Medicare’s annual wellness visit.

Hepatitis B Screening

  • HCPCS G0499 — Hepatitis B screening in non-pregnant, high-risk individual includes hepatitis B surface antigen (hbsag) followed by a neutralizing confirmatory test for initially reactive results, and antibodies to hbsag (anti-hbs) and hepatitis B core antigen (anti-hbc)

  • Other codes may apply for pregnant women.

  • Eligibility: ACA ensured that this screening is covered for people who are considered high risk and for people who are from countries with high rates of hepatitis B prevalence. Patients are also eligible for screening if they were born in the United States and not vaccinated as an infant with one parent from a region with a hepatitis B prevalence rate of at least 8%. Medicare covers hepatitis screenings for both pregnant and non-pregnant women as well as asymptomatic adolescents and adults at high risk for hepatitis B infection.

Hepatitis C Screening

  • HCPCS G0472 — Hepatitis C antibody screening, for individual at high risk and other covered indication(s)

  • Eligibility: Patients who had a blood transfusion prior to 1992 and adults who were born between 1945 and 1965 are eligible for screening once per lifetime and annually for high-risk patients.

HIV Screening

  • HCPCS G0432 — Infectious agent antibody detection by enzyme immunoassay (eia) technique, HIV-1 and/or HIV-2 screening.

  • HCPCS G0433 — Infectious agent antibody detection by enzyme-linked immunosorbent assay (elisa) technique, HIV-1 and/or HIV-2, screening.

  • HCPCS G0435 — Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2 screening.

  • HCPCS G0475 — HIV antigen/antibody, combination assay, screening.

  • Eligibility: This screening is for everyone ages 15 to 65 and can be performed annually. All other ages are eligible for patients who have increased risk factors. There are several codes relevant to their HIV screening.


  • CPT 90670 — Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use.

  • CPT 90732 — Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use.

  • HCPCS G0009 — Administration of pneumococcal vaccine

  • A list of CPT and HCPCS codes and their specific descriptions for the influenza vaccine can be found here.

  • Eligibility: ACA mandated provisions for all recommended vaccines for both adults and children. Patients with Medicare Part B are encouraged to receive a pneumococcal vaccine and an annual influenza vaccine. The pneumococcal vaccine eligibility is subject to Medicare criteria.

Intensive Behavioral Therapy for Cardiovascular Disease (CVD)

  • HCPCS G0446 — Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes.

  • Eligibility: All adults once per year.

Lung Cancer CT Counseling and Screening

  • HCPCS G0296 — Counseling visit to discuss need for lung cancer screening using low dose CT scan (LDCT)

  • HCPCS G0297 — Low dose CT scan (LDCT) for lung cancer screening

  • Eligibility: ACA mandated that high-risk adults who currently or previously smoked within the last 15 years and are between the ages 55 and 80 years old are eligible to receive a lung cancer screening. Medicare beneficiaries may receive a lung cancer screening if they are asymptomatic; have a tobacco use history of at least one pack per day over a 30-year period; are a current smoker; or quit within the last 15 years.

Medical Nutrition Therapy (MNT)

  • CPT 97802 — Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes

  • CPT 97803 — Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes

  • Eligibility: For adults with diabetes, renal disease or who have had a kidney transplant

Obesity Screening and Counseling

  • HCPCS G0447 — Face-to-face behavioral counseling for obesity, 15 minutes

  • HCPCS G0473 — Face-to-face behavioral counseling for obesity, group (2-1), 30 min

  • Eligibility: Payers must provide coverage for obesity screening and counseling for all members. Medicare beneficiaries who have a BMI greater than 30, are competent and alert, and see a qualified practitioner or primary care provider are eligible to receive up to 22 obesity counseling visits in a 12-month period. Visits taper over time. A list of Medicare coverage rules can be found here.

Sexually Transmitted Infection Prevention Counseling

  • A list of sexually transmitted infection CPT and HCPCS codes can be found here.

  • Eligibility: ACA expanded coverage for all adults at high risk of contracting a sexually transmitted disease.

Syphilis Screenings

  • CPT 86592 — Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)

  • CPT 86593 — Syphilis test, non-treponemal antibody, quantitative

  • CPT 86780 — Antibody; treponemal pallidum

  • Eligibility: All at-risk adults are eligible to receive screenings for syphilis.

Tobacco Use Screening

  • CPT 99406 — Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

  • CPT 99407 — Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

  • Eligibility: All adult tobacco users are eligible for screening and cessation interventions regardless of tobacco-related disease symptoms. Per Medicare, patients must be alert and competent and consequent counseling must be performed by a qualified practitioner.

Tuberculosis Screening

  • CPT 86580 — Skin test, tuberculosis, intradermal

  • Eligibility: This screening service is covered for adults meeting certain criteria and are without symptoms or are at a high risk of contracting tuberculosis.


Billing for a Medicare Annual Wellness Visit: HCPCS Codes G0438, G0439, and G0402

The American Medical Association has estimated that about 5% of claims lines are denied by Medicare. Denials can lead to increased days in accounts receivable (A/R), write-off rates, and overall cost to collect, among other headaches for providing organizations. To better ensure that your annual wellness visit (AWV) claims are not denied, proper coding is essential. Not only does accurate coding ensure that practices receive proper reimbursements, but it also protects against penalties incurred from failed coding audits.

What is G0438?

G0438 is the HCPCS code that should be used for a patient’s first annual wellness visit. Its long descriptor is “Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit,” while its short descriptor is “Annual wellness first.”

Two key things to know about G0438:

  1. It can only be used for a Medicare beneficiary who is no longer within the first 12 months after the effective date of their Part B coverage; and
  2. It can only be used for a Medicare beneficiary if they have not already received either an initial preventive physician examination or an AWV within the past 12 months.

Medicare pays for a single initial AWV per beneficiary per lifetime.

What is G0439?

G0439 is the HCPCS code that should be utilized for all subsequent annual wellness visits. Its long descriptor is “Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit,” while its short descriptor is “Annual wellness subseq.”

That said, keep mind that if a practice takes on a new Medicare beneficiary and is providing that patient their first annual wellness visit, practitioners must determine if the beneficiary had an initial AWV provided by another organization. If so, the G0439 code would be used, not G0438 since G0438 was already billed by the other organization that provided the AWV service.

What is G0402?

What is G0402?Broadly speaking, IPPE, also known as the “Welcome to Medicare Visit,” takes place when a practitioner reviews a Medicare beneficiary’s medical and social health history as well as offers education on preventive services. Medicare pays for a single beneficiary IPPE per lifetime that must furnished no later than the first 12 months after the beneficiary’s eligibility date for Medicare Part B benefits.

G0402 is the HCPCS code that should be used for the IPPE. Its long descriptor is “Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment,” while its short descriptor is “Initial preventive exam.”

Additional Codes

Beyond the primary visit codes — HCPCS G0402, HCPCS G0438, and HCPCS G0439 — practitioners may use other codes to bill for services performed during a Welcome to Medicare Visit or AWV. If those additional codes are used, practitioners must include a note that supports the need for each service provided.

Many of these codes have guidelines that require them only to be used with specific visits after meeting certain criteria. For example, HCPCS G0444, used for a 15-minute annual depression screening, can only be added to subsequent wellness visits that are billed under G0439. If that specific code is used with the IPPE or initial AWV, it will be rejected. An abdominal aortic aneurysm (AAA) screening, coded as G0389, can only be provided with the IPPE code G0402 because it is ineligible to be used during AWVs.

Advance care planning (CPT 99497) is considered an optional element of the AWV but is considered a preventive service (and thus has its co-pay waived) when billed on the same day as an AWV with modifier -33.

HCPCS G0442 and HCPCS G0443 are additional codes that must be used in conjunction with each other to be valid. HCPCS G0442 is used for an annual alcohol screening, which should take approximately 15 minutes. G0443 is for 15-minute sessions of alcohol counseling. According to the Centers for Medicare & Medicaid Services, the screening service is required to occur prior to approval for a G0442. Thus, if a practitioner uses G0443 and no claims have been filed for G0442 in the preceding 12 months, the screening code will be denied.

Fifteen-minute obesity counseling sessions may be billed in conjunction with IPPE visits or AWV using HCPCS G0447. When wellness visits last longer than what is typical, prolonged preventive service codes designate a visit takes 30 minutes (G0513) or 60-plus minutes (G0514) past the typical duration of the service.

HCPCS G0438 and G0439: Coding Tips and Mistakes to Avoid

Using similar but different codes can be confusing. Since each visit requires different resources, they must be reimbursed at different rates. For example, during the initial AWV, the practitioner gathers all the patient information that becomes the basis for each subsequent AWV. Thus, as of 2022, the HCPCS G0438 code is reimbursed at a rate more than 30% higher than G0439. If a providing organization regularly neglects to select the G0438 code for an initial Medicare AWV and uses G0439 instead, the practice could lose a great deal of revenue.

Common Misuses of G0438 and G0439

If HCPCS codes G0438 or G0439 are not applied correctly, a denial will likely be triggered. Here are a few typical ways that practices incorrectly code annual wellness visits:

  1. If a practice submits G0438 for a Medicare beneficiary for whom a claim with code G0438 has already been paid, the claim will be denied with a claim adjus tment reason code (CARC) of 149 (“Lifetime benefit maximum has been reached for the service/benefit category.”) and a remittance advice remarks code (RARC) of N117 (“This service is paid only once in a patient’s lifetime.”).
  2. If a practice submits a claim for a G0438 or G0439 within the first 12 months after the effective date of the beneficiary’s first Medicare Part B coverage, it will be denied as that beneficiary is eligible for the IPPE. Such claims will be denied with a CARC of 26 (“Expenses incurred prior to coverage.”) and a RARC of N130 (“Consult plan benefit documents/guidelines for information about restrictions for this service.”).
  3. Do not bill G0438 or G0439 within 12 months of a previous billing of a G0402 (initial preventive physician examination), G0438, or G0439 for the same beneficiary. These subsequent claims will be denied with a C ARC of 119 (“Benefit maximum for this time period or occurrence has been reached.”) and the aforementioned N130 RARC.

Note: Patients are eligible to receive Medicare annual services again on the first of the month they are performed in, one year later. For example, if a patient has an AWV on Nov. 20, 2022, they are eligible again on Nov. 1, 2023.

Additional Annual Wellness Visit Coding Tips

When patients receive their AWV, it is often accompanied by one or more evaluation and management (E&M) services. If what the patient receives can be defined as a “significant, separately identifiable medically necessary E&M service” in addition to the annual wellness visit, CPT codes 99201-99215 may be reported. Along with HCPCS code G0438 or G0439, modifier -25 must be appended to the medically necessary E&M service. CPT guidelines define the -25 modifier as “Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”

Before coding and billing for one or more E&M services, first determine whether some of the components of the medically necessary E&M service, such as a portion of the history exam, were part of the annual wellness visit. If so, these components should not be included when determining the most appropriate level of the billable E&M service.

The HCPCS code G0468 often pops up in resources that describe coding and billing for annual wellness visits. Unless a practitioner works in a federally qualified health center (FQHC), this HCPCS code would not apply. Why? G0468 is solely used by FQHCs to code and bill for AWVs and IPPEs. Its long descriptor is “Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV,” while its short descriptor is “FQHC visit, IPPE or AWV.”

Finally, keep in mind that during the annual wellness visit, many Medicare Part B preventive services may be provided as optional elements, including advance care planning, depression screening, alcohol misuse screen and counseling, and counseling to prevent tobacco use.

Staying Up to Date with AWV Coding Requirements

Occasionally, codes and coding requirements for the annual wellness visit change, so to help avoid being audited because of coding noncompliance, organizations providing AWVs must stay current. Implementing a software solution provided by a vendor that makes maintaining compliance a top priority can help organizations better ensure they code and bill using current rules, thus decreasing the risk of noncompliance and denials, and increasing the likelihood of proper payments.



As spiraling healthcare costs become a greater burden for a growing number of Americans, the healthcare industry must move toward a more cost-effective model of promoting health and wellness through preventive services and exams. Between the prospect of patients living longer, healthier lives and the increasingly generous reimbursements from payers, preventive services should be a core offering for every eligible organization and clinician. When patients receive preventive care, everyone wins.

CPT Copyright 2022 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

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