CurrentMolina HealthcarePolicy N/A

Annual Wellness Visit sooner than 11 months following Initial (IPPE) Policy

Governs billing and reimbursement rules for Initial and Subsequent Annual Wellness Visits (AWV) and the Initial Preventive Physical Examination (IPPE) for Molina Healthcare members, including timing restrictions and documentation requirements affecting providers submitting claims.

Policy Summary

PayerMolina Healthcare

PolicyAnnual Wellness Visit sooner than 11 months following Initial (IPPE) Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill an initial AWV (G0438) or a subsequent AWV (G0439) within 12 months of an IPPE (G0402); ensure thorough documentation of medical necessity and accurate diagnosis codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsminimum interval (months)

1IPPEs per lifetime

YesDocumentation required

TXState exception

Billing and Coverage Criteria

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AWV/IPPE billing and documentation criteria

Billing and reimbursement criteria for preventive visits:

All of the following must be met for AWV/IPPE billing:

ALL of the following

IPPE (G0402) must be billed within 12 months after the start of the patient's first Part B coverage; only one IPPE allowed per patient lifetime.
Initial AWV (G0438) includes a Personalized Prevention Plan Service (PPPS) and must not be billed within 12 months of an IPPE (G0402) for the same patient.
Subsequent AWV (G0439) must not be billed within 12 months of an initial AWV (G0438) or within 12 months of an IPPE (G0402).

Claims must include thorough documentation of medical necessity and accurate diagnosis codes; Molina may deny, audit, or recover payments for incorrect or unsupported claims.

State exceptions

For Texas (TX), follow the Texas Health Steps Periodicity Schedule for guidelines and exemptions for wellness visits.

Relevant Codes and Timing Rules

Medicare wellness HCPCS codesHCPCSCovered

G0402	Initial Preventive Physical Examination (IPPE)
G0438	Initial Annual Wellness Visit (AWV) with Personalized Prevention Plan Service
G0439	Subsequent Annual Wellness Visit (AWV)

Minimum interval between preventive visits — 12 months between IPPE and initial AWV, and between initial AWV and subsequent AWV

Minimum interval12 months between an IPPE (G0402) and an initial AWV (G0438), and 12 months between an initial AWV (G0438) and a subsequent AWV (G0439)

RationalePrevents overlapping preventive visit billing for the same patient within a 12-month period

ApplicabilityApplies to billing for the same patient across IPPE, initial AWV, and subsequent AWV claims

Provider Billing, Documentation, and Audit Actions

Documentation Required

Documentation and Audit — Ensure medical necessity & accurate coding

Molina Healthcare mandates thorough documentation of medical necessity and accurate diagnosis coding. Maintain and retain clinical records that clearly justify the billed service, including history, exam findings, assessments, and any supporting tests or care plans. Claims lacking supporting evidence of medical necessity or correct diagnosis codes may be denied, and Molina may audit paid claims and recover any overpayments.

Ensure medical records substantiate the diagnosis and services billed.
Include the appropriate diagnosis code(s) from Section 2 of Chapter 12 of the Medicare Claims Processing Manual when billing AWV/IPPE codes.
Retain documentation for the period required by Molina and applicable regulations to support audits and appeals.
Be prepared to provide complete medical records if Molina requests an audit or medical review.

Billing Rule

Timing / Prior Authorization-like billing rule

Do not bill an initial AWV (G0438) within 12 months of an IPPE (G0402). Do not bill a subsequent AWV (G0439) within 12 months of an initial AWV (G0438) or within 12 months of an IPPE (G0402).

Affected codes: G0402 (IPPE), G0438 (Initial AWV), G0439 (Subsequent AWV).
IPPE (G0402) is eligible only once per patient and must be billed within 12 months after the start of the patient's first Part B coverage.
Initial AWV (G0438) includes a Personalized Prevention Plan Service (PPPS) and cannot be submitted within 12 months of an IPPE (G0402) for the same patient.
Subsequent AWV (G0439) is not permitted within 12 months of an initial AWV (G0438) or an IPPE (G0402).

Definitions

AWV — Annual Wellness Visit definition

TermAnnual Wellness Visit (AWV)

DefinitionA Medicare preventive visit distinct from an annual physical exam; includes an initial AWV (G0438) with a Personalized Prevention Plan Service and subsequent AWVs (G0439)

Coding examplesInitial AWV (G0438) includes PPPS; Subsequent AWV (G0439) for follow-up annual wellness visits

CMS — Center for Medicare and Medicaid definition

AcronymCMS

DefinitionCenter for Medicare and Medicaid

ContextReferenced as the source of Medicare preventive visit guidance used by Molina Healthcare

HCPCS — Healthcare Common Procedure Coding System definition

AcronymHCPCS

DefinitionHealthcare Common Procedure Coding System

UseUsed to identify preventive service procedure codes such as G0402, G0438, and G0439

IPPE — Initial Preventive Physical Examination definition

TermInitial Preventive Physical Examination (IPPE)

DefinitionA one-time Medicare preventive examination (HCPCS: G0402) billed within 12 months after the start of the patient’s first Part B coverage

LimitEach patient is eligible for only one IPPE in their lifetime