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Medicare denied 10% of all Part B claims on first submission in 2024 (CMS data reported by MedPAC, 2026), and wellness visits fail on dates before anyone reads the note. If an Annual Wellness Visit (AWV) claim breaks a timing rule, Medicare’s system rejects it automatically. The bigger risk is the AWV that gets paid but isn’t backed by the chart: Penn State Health agreed to pay $11,712,336 to resolve allegations over AWV claims that weren’t supported by the medical record (U.S. Department of Justice, 2024).
Which AWV billing errors does Medicare reject automatically?
The ones that break its timing rules, because Medicare’s Common Working File (the central database of every patient’s claims history) checks them by computer. Under CMS Transmittal 2575 (2012), it rejects a first AWV (G0438) if one was ever paid, any AWV within 12 months of a prior AWV, and any AWV within 12 months of a Welcome to Medicare exam (G0402).
It also rejects an AWV billed within 12 months of first Part B coverage. CMS’s current guidance repeats the core rule: G0438 and G0439 are billable once in a 12-month period (CMS, 2026). Hospital-affiliated clinics face one more trap: Medicare pays the practitioner or the facility for an AWV, never both (CMS, 2012).
How does Medicare count the 12 months between wellness visits?
By calendar month, not by days. Medicare counts 11 full months starting with the month after the last paid AWV (CMS Transmittal 2575, 2012). If a visit was paid on March 20, the patient is eligible again on March 1 of the next year, not March 20.
A scheduler set to 365 days will delay patients who are already eligible. One set to “about a year” will book patients too early, and the denial notice sent to the patient says the visit came too soon after the last covered one.
The fix happens at scheduling. Medicare’s systems keep a “next eligible” date for each patient (Transmittal 2575), so ask your Medicare Administrative Contractor (MAC, the company that processes your Medicare claims) which tool shows it, and check it when you book.
What goes wrong when an AWV and a problem visit happen on the same day?
Medicare may pay for both, but only if the second service is a significant, separately identifiable, medically necessary evaluation and management (E/M) visit, meaning a standard office visit code, reported with modifier 25 on the E/M line (CMS, 2026). The usual errors are no modifier, the modifier on the wrong line, or an E/M that can’t stand on its own medical necessity.
Add-on services have their own modifier rule. CMS waives patient cost-sharing for advance care planning (99497) and the physical activity and nutrition assessment (G0136) only when the same provider delivers them the same day and bills them with modifier 33 on the AWV claim (CMS, 2026). Without modifier 33, the waiver doesn’t apply.
Can an AWV be denied or clawed back after it’s paid?
Yes, if the chart doesn’t prove the required elements. CMS lists minimum components for every AWV, including a health risk assessment (HRA, a patient self-report questionnaire), updated medical and family history, a current provider list, measurements, a cognitive impairment check, and a written screening schedule (CMS, 2026).
CMS’s FY2025 report puts the Medicare fee-for-service improper payment rate at 6.55%, or $28.83 billion (CMS, 2026). Insufficient or missing documentation drove 68% of those errors (CMS data reported by MedPAC, 2026). CMS is clear that improper payments are not a measure of fraud (CMS, 2026). These figures cover all Medicare services, not AWVs alone, but the pattern fits: the code can be right and the claim can still fail if the note doesn’t prove the work.
What does a clean AWV workflow look like?
Check eligibility at scheduling, match the code to the visit type, and audit the note against CMS’s element list before the claim leaves your office.
At Reviora Healthcare, human specialists lead that work and technology supports them: Expert-Led Technology, applied across Medical Billing & Coding and Claims & Denial Management. The Reviora Guarantee puts performance in writing through a Managed Outcomes Agreement (MOA), a contractual agreement built on five benchmarks, with a Benchmark Recovery Protocol (BRP) as our accountability mechanism if benchmarks are missed two months in a row.
Wellness visits are core to Primary Care RCM, and any practice billing them can run these same checks. Want a second set of eyes on your AWV claims? Book a 30-minute consult or get started here.
FAQ
How often can you bill an annual wellness visit for Medicare?
Once in a 12-month period. Medicare counts 11 full months from the month after the last paid AWV, so a March visit makes the patient eligible again the following March 1 (CMS, 2012; CMS, 2026).
Can you bill an annual wellness visit and an office visit on the same day?
Yes, if the office visit is significant, separately identifiable, and medically necessary, and you report it with modifier 25 (CMS, 2026).
Does Medicare cover a routine physical exam?
No. CMS lists the routine physical as not covered, with the patient paying 100% out of pocket. The AWV and the Welcome to Medicare exam are the covered visit types (CMS, 2026).
Reference:
- Centers for Medicare & Medicaid Services (CMS). Transmittal 2575, Change Request 8107: Editing Update for Annual Wellness Visit (AWV), Pub. 100-04. October 26, 2012. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2575CP.pdf
- CMS Medicare Learning Network. Annual Wellness Visit. Page updated April 2026. https://www.cms.gov/medicare/coverage/preventive-services/medicare-wellness-visits/annual-wellness-visit
- CMS Medicare Learning Network. Medicare Wellness Visits. Page updated April 2026. https://www.cms.gov/medicare/coverage/preventive-services/medicare-wellness-visits
- U.S. Department of Justice, U.S. Attorney’s Office, Middle District of Pennsylvania. Penn State Health Agrees To Pay More Than Eleven Million Dollars Following Its Voluntary Disclosure Of Improper Billings Related To Medicare Annual Wellness Visit Services. February 7, 2024. https://www.justice.gov/usao-mdpa/pr/penn-state-health-agrees-pay-more-eleven-million-dollars-following-its-voluntary
- CMS. Fiscal Year 2025 Improper Payments Fact Sheet. January 15, 2026. https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-improper-payments-fact-sheet
- Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare and the Health Care Delivery System, Chapter 3, “Medicare payment operations and their role in identifying improper payments.” June 2026. https://www.medpac.gov/wp-content/uploads/2026/06/Jun26_Ch3_MedPAC_Report_To_Congress_SEC.pdf. The 10% Part B initial denial rate (2024) and the 68% documentation share (FY2025) are CMS data as reported in this chapter.