The Annual Wellness Visit (AWV) is one of the most consistently under-utilized preventive care benefits in Medicare. It’s fully covered at zero cost to the patient, it’s billable at a reasonable rate, and it’s a legitimate clinical touchpoint that improves care quality. Yet most primary care practices capture only 20–40% of their eligible Medicare population for this visit each year.
The math on what that costs is straightforward — and it’s usually large enough to surprise practice administrators when they see it for the first time.
What an AWV actually includes
The AWV (G0439 for subsequent years, G0438 for initial) covers a comprehensive health risk assessment, review of the patient’s medical and family history, a list of current providers and suppliers, measurement of height, weight, BMI, blood pressure, and other routine measurements, detection of any cognitive impairment, review of the patient’s potential risk factors for depression and functional ability, and the development or update of a 5–10 year personalized prevention plan.
It’s also an opportunity to bill separately for additional services provided on the same day with modifier 25, and it’s a natural touchpoint for transitional care management documentation.
More importantly: it’s often where chronic conditions get documented that haven’t been captured in the prior year’s claims — which directly affects HCC risk scores and risk-adjusted payment.
The revenue problem
At current Medicare rates (which vary by geography), an AWV typically reimburses at $150–$200 for subsequent visits. That’s the direct billing revenue.
The indirect revenue effect is larger. The AWV is one of the primary mechanisms by which accurate HCC coding gets established for the year. A patient with diabetes, hypertension, and CKD who comes in for an AWV will have those conditions documented and submitted to CMS. A patient who doesn’t come in may have those conditions coded only if they happen to come in for a related acute visit — which may or may not happen, and may or may not get coded correctly.
HCC risk scores directly affect capitated payment rates in Medicare Advantage and risk-adjusted shared savings in MSSP. Undercoding a population’s chronic disease burden by even 10% can mean tens of thousands of dollars in foregone capitation per year for a practice with a few hundred Medicare Advantage patients.
Why practices miss them
The most common reasons:
No visibility into who’s due. Without claims data, practices can’t easily see which patients had an AWV in the prior 12 months. The EHR might know about visits that happened in-house, but if the patient saw another provider for their AWV — or if the AWV was performed at a different location in a prior year — that history isn’t visible.
No outreach infrastructure. Even when a practice knows who’s due, systematically reaching out to schedule preventive visits requires workflow support that most EHRs provide poorly.
Billing confusion. Some staff are uncertain about when a G0439 is appropriate vs. a G0438, or how to handle the interaction with E&M services on the same day. Visits get billed as standard office visits when they could have been billed as AWVs.
What CMS DPC changes
The CMS Data at the Point of Care (DPC) program gives practices access to 24 months of rolling Medicare claims history for their attributed patients. That claims feed includes AWV billing codes — meaning a practice can, for the first time, see exactly which patients have had an AWV in the past 12 months, regardless of where it was performed.
Glance integrates with CMS DPC to surface this as a care gap: patients due for an AWV appear in the outreach worklist with their last AWV date (or “never” if there’s no record), their current chronic condition coding, and their HCC risk score. The practice can prioritize outreach by risk score — highest-risk patients first — and track outreach attempts with timestamps.
The combination of visibility and workflow support is what moves the needle. Practices that have been capturing 25% of eligible patients for AWV regularly reach 50–60% after implementing a systematic DPC-enabled outreach program.
Starting point: know your denominator
Before optimizing AWV capture, you need to know your current rate. That requires two things: knowing who your attributed Medicare population is (from your DPC roster or MA attribution file), and knowing which of those patients had an AWV in the past 12 months (from claims history).
Most practices don’t have an easy way to compute this. If you’re not enrolled in CMS DPC, your denominator is invisible. If you are enrolled but your platform doesn’t surface AWV status as a care gap, you’re getting the data but not acting on it.
This is one of the core use cases Glance was built for. If you’re interested in what your AWV capture rate looks like and what it would mean for your practice to improve it, reach out — we can usually pull those numbers in a first conversation.
