established annual exam under Medicare

what CPT® codes should my doc really be using for an annual exam on a Medicare pt
we have conflicting and arent for sure HELP

re: established annual exam under Medicare

There are two types of AWVs - the first annual wellness visit (G0438) and subsequent annual wellness visits (G0439). G0438 may not be billed if the patient received an IPPE.

The initial Annual Wellness Visit (G0438) includes:

routine measurements such as height, weight, blood pressure, body-mass index (or waist circumference, if appropriate);
review of medical and family history;
establishing a list of current providers, suppliers, and medications (including supplements);
a personal risk assessment (including any mental health conditions);
a review of functional ability and level of safety;
detection of any cognitive impairment;
screening for depression;
establishing a schedule for Medicare’s screening and preventive services your client qualifies for over the next 5 to 10 years; and,
any other advice or referral services that may help intervene and treat potential health risks.
The subsequent Annual Wellness Visits (G0439) include:

measurement of weight, blood pressure, and other measurements deemed appropriate (note: height and body-mass index not necessary, unless your client has had significant weight change);
an update to medical and family history;
an update to the list of providers, suppliers, and medications (including supplements);
a review of the initial personal risk assessment;
detection of any cognitive impairment;
an updated screening schedule; and,
a review and update to list of referral services to help intervene and treat potential health risks.

re: established annual exam under Medicare

But don't use the wellness visit codes unless you meet the criteria for them. If you are doing a typical preventive medicine service it is still non-covered and must be billed to the patient. Obtain an ABN.