Medicare Annual Wellness Visits require more than selecting G0438 or G0439. The medical record should demonstrate that the required assessment, review, screening, and prevention-planning components were completed.
This annual wellness visit documentation checklist gives primary care practices a practical framework for organizing AWV documentation, supporting Medicare billing, and reducing preventable claim problems.
The checklist is an operational guide—not a replacement for current CMS, Medicare Administrative Contractor, payer, coding, or compliance requirements.
What Is Required for an Annual Wellness Visit?
A Medicare Annual Wellness Visit focuses on health-risk assessment and preventive planning. It is not the same as a routine comprehensive physical examination.
The two primary AWV billing codes are:
- G0438: Initial Annual Wellness Visit
- G0439: Subsequent Annual Wellness Visit
The initial AWV establishes the patient’s personalized prevention plan. Subsequent visits update the patient’s health-risk information, screening schedule, provider list, medications, and prevention plan.
Before documenting the visit, verify which service the patient is eligible to receive. Review our complete guide to annual wellness visit CPT codes for the differences between G0402, G0438, and G0439.
Use the official CMS Annual Wellness Visit guidance to confirm eligibility, required components, coding, and billing before applying this annual wellness visit documentation checklist.
15-Step Annual Wellness Visit Documentation Checklist
1. Verify the Patient’s Medicare Eligibility
Before the appointment, confirm:
- The Medicare Part B effective date
- Whether the patient previously received G0402
- Whether G0438 has already been billed
- The date of the most recent G0438 or G0439 service
- Whether the required interval has passed
G0438 is generally available once during a beneficiary’s lifetime. G0439 is used for subsequent eligible Annual Wellness Visits.
Do not select G0438 simply because the patient is new to your practice. Eligibility follows the patient’s Medicare history, not the provider relationship.
2. Identify the Correct Visit Type
Document whether the appointment is:
- An Initial Annual Wellness Visit billed with G0438
- A Subsequent Annual Wellness Visit billed with G0439
- A Welcome to Medicare visit billed with G0402
- A routine physical not covered as an AWV
- A problem-oriented evaluation and management visit
The record should clearly identify the service performed. Using vague terms such as “annual examination” or “yearly physical” can create confusion if the documentation does not reflect Medicare’s AWV requirements.
3. Complete the Health-Risk Assessment
The health-risk assessment is a central component of the Annual Wellness Visit.
Document applicable information concerning:
- Demographics
- Self-assessment of health
- Psychosocial risks
- Behavioral risks
- Activities of daily living
- Instrumental activities of daily living
- Functional ability
- Safety concerns
The assessment may be completed before or during the appointment, but the practitioner should review and incorporate the information into the prevention plan.
A form stored in the chart without evidence of review may not adequately demonstrate that the information was addressed.
Using an annual wellness visit documentation checklist helps ensure the completed health-risk assessment is reviewed and incorporated into the patient’s prevention plan.
4. Update Medical and Family History
Document or update the patient’s relevant medical and family history.
The record may include:
- Current and previous illnesses
- Hospitalizations
- Surgical history
- Allergies
- Family history
- Significant injuries
- Relevant chronic conditions
- Other clinically important risk information
Avoid automatically carrying forward information without confirming that it remains accurate.
5. Document Current Providers and Suppliers
Create or update the list of healthcare professionals and suppliers involved in the patient’s care.
This may include:
- Primary care providers
- Specialists
- Behavioral health professionals
- Home-health agencies
- Pharmacies
- Durable medical equipment suppliers
- Other clinicians or organizations involved in treatment
The list helps support care coordination and the development of an accurate prevention plan.
6. Reconcile Medications and Supplements
Record the patient’s current:
- Prescription medications
- Over-the-counter medications
- Vitamins
- Herbal products
- Dietary supplements
The documentation should demonstrate that the medication list was reviewed or updated during the visit.
Medication discrepancies, duplication, or safety concerns should be handled according to the practice’s clinical procedures.
7. Record Required Routine Measurements
Document the measurements applicable to the Annual Wellness Visit, which may include:
- Height
- Weight
- Body mass index
- Blood pressure
- Waist circumference when appropriate
- Other measurements based on the patient’s medical and family history
Values should be entered into the medical record rather than recorded only on an unconnected worksheet.
8. Assess Cognitive Function
The practitioner should assess the patient for signs of potential cognitive impairment.
The assessment may consider:
- Direct observation
- Information from the patient
- Concerns reported by family members or caregivers
- Changes in memory, judgment, or daily functioning
- Results of an appropriate assessment instrument when used
The record should document the assessment and relevant findings. If possible cognitive impairment is identified, a more detailed evaluation may be clinically appropriate, but it is not automatically included in the AWV.
9. Review Depression and Behavioral Health Risks
Document the review of potential depression, mood, and behavioral-health risks when applicable.
The practitioner may consider:
- Patient-reported symptoms
- Previous behavioral-health diagnoses
- Current treatment
- Medication use
- Observed mood or behavior
- An appropriate standardized screening instrument
Do not assume that a separately billable behavioral-health screening is automatically supported simply because questions were asked during the AWV. Confirm the requirements for any additional service.
10. Evaluate Functional Ability and Safety
Document the patient’s functional ability and level of safety.
Relevant areas may include:
- Hearing
- Fall risk
- Ability to perform activities of daily living
- Ability to manage medications
- Home-safety concerns
- Mobility
- Need for assistance
- Potential risks identified by the patient or caregiver
When concerns are identified, document the advice, referral, follow-up, or other action taken.
11. Establish or Update the Screening Schedule
Create or update a written screening schedule based on the patient’s:
- Age
- Sex
- Medical history
- Family history
- Risk factors
- Previous preventive services
- Applicable Medicare preventive-service recommendations
The schedule should identify preventive services that may be appropriate during the coming years.
Do not document that a screening was completed unless the service was actually performed. The AWV may identify and recommend preventive services without including each service in the AWV itself.
12. Document the Personalized Prevention Plan
The personalized prevention plan should reflect the risks and needs identified during the visit.
It may include:
- Preventive services due
- Health advice
- Education
- Counseling
- Referrals
- Risk-reduction recommendations
- Follow-up needs
- Community-based resources
- Other appropriate preventive interventions
The plan should be individualized. A generic template containing identical recommendations for every patient may not clearly demonstrate personalized preventive planning.
13. Separate Additional E/M Work
A medically necessary office or outpatient E/M service may sometimes be performed on the same date as an AWV.
If an additional E/M service is billed, document:
- The separate complaint or condition addressed
- Relevant history and examination
- Medical decision-making or qualifying time
- Assessment
- Treatment plan
- Why the additional work exceeded the AWV requirements
Modifier 25 is generally appended to the separately identifiable E/M service—not to G0438 or G0439.
Routine review of stable conditions during the wellness visit does not automatically support an additional 99213 or 99214 service.
14. Review Other Separately Reported Services
Before claim submission, determine whether other services were performed and separately reportable.
Possible examples may include:
- Advance care planning
- Depression screening
- Cardiovascular risk assessment
- Social determinants of health assessment
- Vaccinations
- Other Medicare preventive services
- A separately identifiable office or outpatient E/M service
- G2211 when connected to an eligible E/M service and current requirements are met
Each additional service must meet its own coverage, documentation, coding, modifier, frequency, and medical-necessity requirements.
Do not add services merely to increase reimbursement. The medical record must support what was actually performed.
15. Complete a Final Billing and Documentation Review
Before releasing the claim, confirm:
- The patient was eligible for the selected AWV
- The correct code was chosen
- The health-risk assessment was completed and reviewed
- Medical and family history was updated
- Providers and suppliers were documented
- Medications and supplements were reviewed
- Required measurements were recorded
- Cognitive function was assessed
- Functional and safety risks were reviewed
- The screening schedule was established or updated
- Personalized prevention advice was documented
- Additional services were separately supported
- Modifiers were applied correctly
- The diagnosis information was appropriate
- The note was signed and completed
This final review helps identify missing information before the claim reaches Medicare.
A consistent annual wellness visit documentation checklist can help the practice identify missing information before the claim is submitted.
G0438 Documentation Requirements
The G0438 documentation requirements should demonstrate that the patient received an initial Annual Wellness Visit and that the practitioner established a personalized prevention plan.
The record should support the initial collection and review of the applicable health-risk, medical, family, medication, provider, measurement, cognitive, functional, and preventive-service information.
G0438 should not be billed again merely because:
- The patient changed providers
- The patient joined a new practice
- The practice changed EHR systems
- The previous AWV documentation is unavailable internally
Verify Medicare history before submitting the claim.
G0439 Documentation Requirements
The G0439 documentation requirements focus on updating the information collected during the initial AWV.
The record should demonstrate that the practitioner reviewed and updated applicable elements, including:
- Health-risk information
- Medical and family history
- Providers and suppliers
- Medications and supplements
- Routine measurements
- Cognitive status
- Functional and safety concerns
- Screening schedule
- Personalized prevention plan
Avoid copying the previous AWV note without documenting what was reviewed, what changed, and what recommendations were made during the current encounter.
Common Annual Wellness Visit Documentation Mistakes
Calling the AWV a Routine Physical
An Annual Wellness Visit is a preventive-planning service. It should not be documented as though it were a comprehensive routine physical unless a different service was actually performed and billed appropriately.
Missing the Health-Risk Assessment
A brief note stating “wellness visit completed” does not demonstrate the required assessment and personalized prevention-planning work.
Using G0438 for Every New Medicare Patient
G0438 is the beneficiary’s initial AWV, not the first AWV performed by each practice.
Copying Forward Outdated Information
Medication lists, provider lists, risk factors, and preventive recommendations should be reviewed for accuracy during the current encounter.
Automatically Billing an Additional E/M Service
The presence of chronic conditions does not automatically support an additional office-visit code. The record must demonstrate significant, separately identifiable, medically necessary work.
Automatically Applying Modifier 25
Modifier 25 should be used only when the separately reported E/M service meets the applicable requirements.
Failing to Document the Prevention Plan
The record should show the screening schedule, personalized advice, referrals, or preventive recommendations developed or updated during the visit.
How an AWV Documentation Template Can Help
A structured template can help practitioners remember required elements and create a consistent workflow.
However, the template should:
- Allow patient-specific information
- Distinguish G0438 from G0439
- Separate AWV work from problem-oriented E/M services
- Identify incomplete elements
- Avoid automatically importing inaccurate information
- Produce a readable medical record
- Support the services reported on the claim
A checklist supports documentation, but it does not replace professional judgment or current payer requirements.
Practices should customize their annual wellness visit documentation checklist to match current Medicare requirements and their clinical workflow.
Frequently Asked Questions
What should be documented for a Medicare Annual Wellness Visit?
The record should support the applicable health-risk assessment, medical and family history, provider and medication lists, routine measurements, cognitive review, functional and safety assessment, screening schedule, and personalized prevention plan.
Is a physical examination required for an Annual Wellness Visit?
An AWV is not the same as a routine comprehensive physical examination. The practitioner should complete and document the elements required for the applicable Medicare wellness service.
Can G0438 be billed for a patient who is new to the practice?
Only if the beneficiary has not previously received an initial Medicare AWV and otherwise meets the eligibility requirements. Being new to the practice does not independently establish G0438 eligibility.
Can 99213 or 99214 be billed with G0438 or G0439?
Yes, when a significant and separately identifiable, medically necessary E/M service is performed and documented beyond the AWV requirements. Modifier 25 is generally appended to the E/M code.
Should the health-risk assessment be stored in the medical record?
The health-risk information should be available as part of the documentation supporting the service. The practitioner should also demonstrate that the information was reviewed and incorporated into the patient’s prevention plan.
Can G2211 be billed directly with G0438 or G0439?
G2211 is associated with an eligible office or outpatient E/M base service. It is not appended directly to the AWV code. Current Medicare requirements must be satisfied before reporting it.
Improve Your Annual Wellness Visit Workflow
A reliable annual wellness visit documentation checklist helps connect scheduling, eligibility verification, clinical documentation, coding, and claim review.
The Ashez Group supports primary care practices with medical billing, eligibility verification, coding review, claim submission, denial management, and accounts-receivable follow-up.
Request a Medical Billing Consultation to discuss your Annual Wellness Visit billing workflow.
Disclaimer: This article provides general educational information and does not replace current CMS, Medicare Administrative Contractor, payer, legal, coding, or compliance guidance. Requirements may change and should be verified for the applicable patient, payer, location, and date of service.
