Skip to main content
HCPCS G0438 · Level II · G code

G0438: Annual wellness visit; includes a personalized prevention plan of service (PPS), HCPCS Level II G code

Compiled from CMS files by the QuickIntell RCM Editorial Team · Data effective · Method: reference methodology · Report a data correction

Data currency: HCPCS Level II file: October 2026 (effective October 1, 2026); PFS relative value file: RVU26D, released August 26, 2026 (effective October 1, 2026); NCCI MUE tables: 2026 Q4 (effective October 1, 2026); NCCI PTP edits: v323r0 (2026 Q4) (effective October 1, 2026); OPPS Addendum B: October 2026 (effective October 1, 2026). Next CMS release: January 1, 2027 (quarterly update) for the HCPCS Level II file and NCCI MUE tables and NCCI PTP edits and OPPS Addendum B; RVU27A with the CY2027 PFS final rule, effective January 1, 2027 for the PFS relative value file.

Key facts for G0438

Medicare payment
$174.35
PFS non-facility, national
Coverage code
C
carrier judgment, so the Medicare contractor decides coverage
Practitioner MUE
1
MAI 2
OPPS status
SI A
Services not paid under OPPS; paid under fee schedule or other payment system
NCCI PTP pairs
95
85 hospital outpatient
LCDs and articles
0 / 0
on the Medicare telehealth list

TL;DR

HCPCS Level II G0438 reads "Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit" in the October 2026 file; it dates from 2011. Medicare's October 2026 physician fee schedule pays G0438 $174.35 non-facility and no facility amount facility nationally, from 2.60 work, 2.45 practice-expense and 0.17 malpractice RVUs at the $33.4009 conversion factor. Qualifying APM participants get $175.22 at $33.5675. MUE limits for G0438: practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction). G0438 is a primary code for 2 add-on codes (G0506, G0513). In the NCCI PTP files v323r0 G0438 appears in 2 practitioner pairs as column 2 and 93 as column 1 (most often with 99483, G0402), and in 2 hospital outpatient pairs as column 2 and 83 as column 1. No current LCD or billing article lists G0438; its HCPCS coverage code is C (carrier judgment, so the Medicare contractor decides coverage). It is on the CY2026 Medicare telehealth list (CMS action: Maintain). OPPS status indicator A: Services not paid under OPPS; paid under fee schedule or other payment system. HCPCS record: BETOS M5D (specialist - other); pricing indicator 11; type of service 1 (medical care). 1 other active code opens with "Annual wellness visit"; related codes: G0439, G0442, G0433, G0443.

G0438 descriptor and code status

The October 2026 HCPCS Level II file describes G0438 as “Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit”. It sits in the G section (procedures and professional services, temporary), listed with the other G codes. Although searches often call it the "G0438 CPT code", G0438 is a HCPCS Level II code maintained by CMS, not an AMA CPT code; both go in the same procedure-code field on the claim.

HCPCS file attributes of G0438
FieldValue
Short descriptorPpps, initial visit
Added to HCPCS2011-01-01
Last actionN (no maintenance), effective 2026-01-01
Coverage codeC: carrier judgment, so the Medicare contractor decides coverage
Pricing indicator11: physician fee schedule, priced with national RVUs
BETOS categoryM5D: specialist - other
Type of service1: medical care

Medicare payment for G0438

Medicare's October 2026 physician fee schedule pays G0438 $174.35 non-facility and no facility amount facility nationally, from 2.60 work, 2.45 practice-expense and 0.17 malpractice RVUs at the $33.4009 conversion factor. Qualifying APM participants get $175.22 at $33.5675. The amounts below are national figures from the October 2026 CMS files; the contractor applies the locality, rural or state adjustment and the beneficiary's cost sharing.

Physician fee schedule (RVU26D)

Status A: active: paid separately under the physician fee schedule when covered. Global period XXX (global surgery concept does not apply); PC/TC indicator 0 (physician service; the professional/technical split does not apply).

PFS relative values and national payment for G0438
ComponentNon-facilityFacility
Work RVU2.602.60
Practice expense RVU2.45NA
Malpractice RVU0.170.17
Total RVUs5.22NA
National payment (CF $33.4009)$174.35n/a
Qualifying APM participant (CF $33.5675)$175.22n/a
  • Multiple procedures (modifier 51): no multiple-procedure reduction
  • Bilateral (modifier 50): 150% bilateral adjustment does not apply
  • Assistant at surgery: assistant at surgery paid only with documentation; co-surgeons: co-surgeons not permitted; team surgery: team surgeons not permitted
  • Physician supervision of diagnostic procedures: supervision concept does not apply

Hospital outpatient (OPPS Addendum B)

Status indicator A (Services not paid under OPPS; paid under fee schedule or other payment system), with no separate OPPS payment rate.

Medically Unlikely Edits for G0438

MUE limits for G0438: practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction). The practitioner MUE is a date-of-service policy edit: units above the limit deny even when split across lines, and appeals rarely succeed.

MUE values for G0438 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services12 Date of Service Edit: PolicyCode Descriptor / CPT Instruction
Facility outpatient hospital12 Date of Service Edit: PolicyCode Descriptor / CPT Instruction

The MUE lookup for G0438 shows every setting next to any other code on the same claim.

NCCI edits and add-on rules

In the practitioner PTP file v323r0, G0438 is the column-2 (bundled) code in 2 active pairs, 50% of which allow a modifier and the column-1 code in 93 (74% modifier-allowed); 165 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: Mutually exclusive procedures.

Column-1 codes most often paired with G0438 (practitioner)
Column-1 codePairs
99483 (CPT; descriptor licensed by AMA)1
G0402 Initial preventive exam1
Column-2 codes bundled into G0438 (practitioner)
Column-2 codePairs
36591 (CPT; descriptor licensed by AMA)1
36592 (CPT; descriptor licensed by AMA)1
90791 (CPT; descriptor licensed by AMA)1
90792 (CPT; descriptor licensed by AMA)1
90832 (CPT; descriptor licensed by AMA)1
90833 (CPT; descriptor licensed by AMA)1
90834 (CPT; descriptor licensed by AMA)1
90836 (CPT; descriptor licensed by AMA)1

In the hospital outpatient PTP file v323r0, G0438 is the column-2 (bundled) code in 2 active pairs, 50% of which allow a modifier and the column-1 code in 83 (83% modifier-allowed); 156 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: Mutually exclusive procedures.

Column-1 codes most often paired with G0438 (hospital outpatient)
Column-1 codePairs
99483 (CPT; descriptor licensed by AMA)1
G0402 Initial preventive exam1
Column-2 codes bundled into G0438 (hospital outpatient)
Column-2 codePairs
90791 (CPT; descriptor licensed by AMA)1
90792 (CPT; descriptor licensed by AMA)1
90832 (CPT; descriptor licensed by AMA)1
90833 (CPT; descriptor licensed by AMA)1
90834 (CPT; descriptor licensed by AMA)1
90836 (CPT; descriptor licensed by AMA)1
90837 (CPT; descriptor licensed by AMA)1
90838 (CPT; descriptor licensed by AMA)1

G0438 is a designated primary code for 2 add-on codes (G0506, G0513).

Pair counts show exposure, not the answer for one claim. Check G0438 against a second code to see whether the pair bundles and whether a modifier can separate the services.

Medicare coverage policies for G0438

No current LCD or billing and coding article lists G0438. The HCPCS coverage code C means carrier judgment, so the Medicare contractor decides coverage, and any National Coverage Determination for the service still applies.

Telehealth status

G0438 is on the CY2026 Medicare telehealth services list (CMS action: Maintain). Bill it with the place-of-service code and modifiers that match where the patient and the practitioner are on the date of service.

Denials to expect on G0438

CARC 50 · N115

the service is not reasonable and necessary for the diagnosis on the claim

CARC 151 · N362

units of G0438 exceed the practitioner MUE of 1 per date of service

CARC 4

the modifier reported is inconsistent with the code

CARC 16

the claim lacks information needed to adjudicate the line, such as an order, NPI or required modifier

Where QuickIntell fits for G0438 claims

QuickCode supports qualified coder review of units, modifiers and NCCI pairs for G0438 before the claim leaves, and QuickRCM carries claim readiness and the denial follow-up when an edit or coverage policy is missed.

See QuickCode for coder reviewSee QuickRCM for denial follow-upBook a meeting

Frequently asked questions: HCPCS G0438

What does HCPCS code G0438 describe?

"Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit" (short descriptor "Ppps, initial visit"), in the G section (procedures and professional services, temporary). Added 2011-01-01; last action N (no maintenance) effective 2026-01-01.

Is G0438 a CPT code?

No: CMS maintains G0438 in HCPCS Level II, while the AMA maintains CPT. People do search "G0438 CPT code", and it goes in the same procedure-code field.

What does Medicare pay for G0438?

Medicare's October 2026 physician fee schedule pays G0438 $174.35 non-facility and no facility amount facility nationally, from 2.60 work, 2.45 practice-expense and 0.17 malpractice RVUs at the $33.4009 conversion factor. Qualifying APM participants get $175.22 at $33.5675.

Is G0438 an add-on code?

G0438 is a primary code for 2 add-on codes (G0506, G0513).

How many units of G0438 can be billed per day?

MUE limits for G0438: practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction). For the practitioner MUE (MAI 2), units above 1 deny for the whole day as a policy limit; denials arrive as CARC 151.

Does Medicare cover G0438?

No current LCD or billing article lists G0438; its HCPCS coverage code is C (carrier judgment, so the Medicare contractor decides coverage).

Can G0438 be billed as telehealth?

Yes. G0438 is on the CY2026 Medicare telehealth list (Maintain); the place-of-service and modifier rules on the date of service still apply.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.

Disclaimer

This page is an operational reference compiled from CMS publications: the HCPCS Level II file, the physician, DMEPOS and clinical laboratory fee schedules, OPPS and ASC addenda, NCCI MUE, PTP and add-on edit tables and the Medicare Coverage Database. Amounts are Medicare national figures before locality and state adjustment; Medicaid and commercial payers set their own. CPT codes are shown as numbers only; CPT descriptors are copyright AMA. Nothing here is legal, clinical or billing advice.

Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.