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    v1.0.28
    OpenPayerPolicy UpdatesPreventive Services & Screeningalacura_medical_transportation_management IPPE AWV…
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    Currentalacura_medical_transportation_managementPolicy N/A

    Medicare Initial Preventive Physical Exam (IPPE) and Annual Wellness Visit (AWV) Coverage Criteria

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    Guidance on coverage, required components, coding, timing, and documentation for the Medicare 'Welcome to Medicare' IPPE and Annual Wellness Visits (initial and subsequent) for Medicare Part B beneficiaries.

    Policy Summary
    Payeralacura_medical_transportation_management
    PolicyMedicare Initial Preventive Physical Exam (IPPE) and Annual Wellness Visit (AWV) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionEnsure visits include required components and documentation (history, exam, screenings, counseling, and a written screening schedule or personalized prevention plan) to support coverage.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    G0402IPPE CPT/HCPCS code
    G0438, G0439

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Initial & Subsequent AWV codes
    100%Medicare payment rate
    OnceIPPE frequency
    Every 12 moSubsequent AWV frequency

    Coverage Criteria

    Coverage Criteria

    Covered when the visit and its components meet Medicare IPPE or AWV requirements:

    IPPE timing and frequency: IPPE (G0402) must occur within the first 12 months of Medicare Part B enrollment and is covered only once in a lifetime.timing: within 12 months; frequency: once

    See required components for IPPE.

    Initial AWV timing: Initial AWV (G0438) is provided after the first 12 months of Medicare Part B enrollment and must be at least 1 year + 1 day after the IPPE if the IPPE was provided.timing: >12 months and >=1 year + 1 day after IPPE
    Subsequent AWV frequency: Subsequent AWV (G0439) is allowed every 12 months; AWV G-codes may be used anytime within the calendar year to allow scheduling flexibility.every 12 months or within calendar year rule

    Determine prior preventive service date from CMS eligibility systems or MACs.

    Required visit components (IPPE and AWV): Visits must include medical/surgical history; review of sexual health and history of alcohol, tobacco and illicit drug use; family history; review of psychosocial risk factors; review of functional ability and level of safety; exam including height, weight, BMI, blood pressure; education/counseling/referral based on results; and a written screening schedule for a minimum of 5 years.components as listed

    Include current medications and supplements, diet, physical activities, and appropriate screening instruments (e.g., PHQ-9).

    Additional IPPE components: IPPE additionally includes visual acuity screening, end-of-life planning, a screening EKG as appropriate (once in a lifetime), and other condition-specific screenings such as abdominal aortic aneurysm (AAA) ultrasound when indicated by family history or in males age 65–75 with a smoking history — AAA ultrasound is covered only with referral from the IPPE.components as listed

    AAA ultrasound coverage limited to those meeting family history or age/smoking criteria and requires referral from IPPE.

    Additional AWV components: AWV includes, in addition to the shared components: review of a completed health risk assessment; list of medical providers and suppliers; detection of cognitive impairment; advance care planning discussion at the patient's discretion; list of patient risk factors and conditions; and a personalized prevention plan or health advice with referrals as appropriate.components as listed

    Include cognitive assessment and personalized prevention plan for AWV.

    Abdominal aortic aneurysm (AAA) ultrasound screening is not broadly covered for all Medicare beneficiaries; it is covered only when ordered as a referral from the IPPE and limited to beneficiaries with an appropriate family history or males aged 65–75 with a smoking history.

    The document does not list any additional exclusions or limitations beyond the specific screening referral and population restrictions described for certain IPPE screenings (for example, AAA ultrasound).

    Coding and Timing

    Covered HCPCS Codes - IPPEHCPCSCovered
    G0402IPPE
    Covered HCPCS Codes - AWVHCPCSCovered
    G0438Initial AWV
    G0439Subsequent AWV
    inv-06: AWV timing relative to IPPE
    RequirementAWV must be performed at least 1 year plus 1 day after the IPPE when an IPPE was provided.
    ApplicabilityApplies to initial AWV (G0438) when member previously received the IPPE (G0402).
    Documentation referenceConfirm prior IPPE date via CMS eligibility systems or Medicare Administrative Contractor before billing AWV.
    inv-07: Subsequent AWV frequency
    FrequencySubsequent AWVs are allowed every 12 months.
    Coding flexibilityAWV G‑codes (G0438, G0439) may be used anytime within the calendar year to increase scheduling flexibility, regardless of the 12‑month/365‑day rule.

    Provider Actions, Documentation & Requirements

    Prior Authorization

    Referrals required for select screenings (IPPE)

    Certain condition-specific screenings referenced in the policy (for example, abdominal aortic aneurysm ultrasound) are covered only when ordered as a referral from the IPPE; no prior authorization is indicated for the IPPE itself.

    • Abdominal aortic aneurysm ultrasound: covered only with referral from the IPPE for patients with relevant family history or males age 65–75 with a smoking history.
    Step Therapy

    Step therapy: Not applicable

    The policy specifies that step therapy does not apply to these preventive visits.

    Background

    The Welcome to Medicare Initial Preventive Physical Exam (IPPE) is intended to occur within the first 12 months of Medicare Part B enrollment and is covered once in a lifetime. The IPPE focuses on preventive screening, risk-factor assessment, counseling and establishment of a written screening schedule (minimum 5 years), and includes additional elements such as visual acuity screening, end-of-life planning, and select condition-specific screenings or tests when appropriate.

    Definitions

    inv-13: Definition — IPPE
    DefinitionWelcome to Medicare Initial Preventive Physical Exam (IPPE) provided within the first 12 months of Medicare Part B enrollment; covered once in a lifetime.
    HCPCS codeG0402.
    Required components (summary)Medical/surgical history, family history, psychosocial risk review, functional assessment, exam (height, weight, BMI, BP), education/counseling/referral, written screening schedule for minimum 5 years; plus IPPE‑specific items such as visual acuity screening, end‑of‑life planning, and screening EKG (once in a lifetime as appropriate).
    inv-14: Definition — Annual Wellness Visit (initial and subsequent)
    DefinitionAnnual Wellness Visit (initial and subsequent) provided after the first 12 months of Medicare Part B enrollment and at least 1 year plus 1 day after the IPPE if IPPE was provided.
    HCPCS codes
    Policy Summary
    Payeralacura_medical_transportation_management
    PolicyMedicare Initial Preventive Physical Exam (IPPE) and Annual Wellness Visit (AWV) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionEnsure visits include required components and documentation (history, exam, screenings, counseling, and a written screening schedule or personalized prevention plan) to support coverage.
    SourceLink
    On This Page
    Coverage CriteriaCoding and TimingProvider Actions, Documentation & RequirementsBackgroundDefinitions
    Verify last preventive serviceDetermine the date of the member's last preventive service using CMS HIPAA Eligibility Transaction System or the Medicare Administrative Contractor.
    Documentation Required

    Required documentation elements

    Providers must include core patient and visit identifiers and ensure the note is signed by a credentialed provider; document how diagnoses were addressed and capture medication, social and functional elements.

    • Patient demographics (name, date of birth) and date of service in progress notes
    • Credentialed provider signature and date
    • Documentation of how each diagnosis was monitored, evaluated, assessed and/or treated on the date of service
    • Current medications and supplements, diet, physical activities
    • Psychosocial risk factors and screening results (e.g., PHQ-9 when used)
    • Assessment of functional ability, fall risk, activities of daily living
    Denial Risk

    Required visit content and denial risk for missing elements

    Visits must contain the required clinical components for IPPE/AWV and a written prevention or screening schedule; missing these components or required documentation may place the claim at risk of denial.

    • Medical/surgical history, including sexual health and substance use history
    • Review of psychosocial risk factors (stress, pain, fatigue, depression) and review of systems
    • Exam elements: height, weight, BMI, blood pressure (and visual acuity for IPPE)
    • Education, counseling and referrals based on results
    • Written screening schedule for minimum 5 years (IPPE) or a personalized prevention plan for AWV
    • IPPE-specific items: visual acuity screening, end-of-life planning, screening EKG as appropriate (once in a lifetime)
    Initial AWV: G0438; Subsequent AWV: G0439.
    Visit content (summary)Includes medical/surgical history, psychosocial risk review, functional ability and safety, exam elements (height, weight, BMI, BP), education/counseling/referral, and a personalized prevention plan; subsequent AWVs allowed every 12 months.