A two-physician internal medicine practice asked us to look at why its Medicare revenue per patient was lower than a similar practice down the road. The visit counts were the same. The annual wellness visits were billed. The difference was everything around the wellness visit. The other practice was billing alcohol screening, depression screening and tobacco cessation counseling on the same day as G0439, and cardiovascular and obesity counseling at follow-up visits. The first practice was doing most of that work, documenting it in the wellness visit template, and billing none of it.
This is the most common pattern we see with Medicare preventive services. The annual wellness visit (AWV) is well understood. The dozen or so separately payable screening and counseling services that sit next to it are not, partly because each one has its own frequency limit, its own time requirement and its own diagnosis code habits. Bill one too often and you get a frequency denial; skip them and you leave money on the table for work you already did.
Key takeaways
- Medicare pays separately, with no deductible or coinsurance, for alcohol misuse screening (G0442) and counseling (G0443), depression screening (G0444), tobacco cessation counseling (99406 and 99407), cardiovascular behavioral therapy (G0446) and obesity behavioral therapy (G0447), on top of the wellness visit.
- Each service has a frequency limit: once per 12 months for the screenings and G0446, four per year for G0443, eight sessions per year for tobacco counseling, and up to 22 visits per year for G0447 with a weight-loss condition at month six.
- HCPCS G0136, introduced in 2024 as the social determinants of health risk assessment, was revised for 2026 to a physical activity and nutrition assessment; it remains a 5 to 15 minute service, once every six months, and an optional AWV element.
- Annual means 11 full months must pass after the month of the last service, not a calendar year, and payers count from their own claims history, not your chart.
- The documentation is short for every one of these, but it must show the time or the tool used and the result, and it must be separate from the AWV elements.
The Medicare preventive services list that sits beside the AWV
| Code | Service | Time or tool | Frequency limit |
|---|---|---|---|
| G0442 | Annual alcohol misuse screening | Up to 15 minutes, validated tool such as AUDIT-C | Once per 12 months |
| G0443 | Brief face-to-face behavioral counseling for alcohol misuse | 15 minutes | Up to 4 per 12 months, after a positive screen |
| G0444 | Annual depression screening | Up to 15 minutes, validated tool such as PHQ-2 or PHQ-9 | Once per 12 months |
| 99406 | Tobacco cessation counseling, intermediate | More than 3 and up to 10 minutes | 2 attempts per year, 4 sessions each, 8 total |
| 99407 | Tobacco cessation counseling, intensive | More than 10 minutes | Counts toward the same 8 sessions |
| G0446 | Intensive behavioral therapy for cardiovascular disease | 15 minutes | Once per 12 months |
| G0447 | Behavioral therapy for obesity, individual | 15 minutes, BMI 30 or higher | Up to 22 in 12 months on a set schedule |
| G0136 | Standardized physical activity and nutrition assessment (SDOH risk assessment through 2025) | 5 to 15 minutes, standardized tool | Once every 6 months |
Two things about this table. First, all of these are Medicare Part B preventive benefits with cost sharing waived, so the patient owes nothing for them, which is worth telling the patient at the desk. Second, G0442, G0444 and G0446 are defined for the primary care setting, and Medicare's coverage decisions expect them to be furnished where staff-assisted follow-up is available. A specialist practice billing G0444 will draw attention.
Frequency limits and how Medicare counts them
"Annual" in Medicare preventive billing means at least 11 full months have passed following the month in which the last service was performed. If a patient had G0444 on March 12, 2025, the next one is payable on or after March 1, 2026. Payers count from their own paid claims, so a patient who had the screening at another practice last June is not eligible with you until this June, whether or not you knew about it. The eligibility response from Medicare (the HETS 270/271 transaction, which most practice management systems display as "preventive service dates") shows the last date paid for the major preventive codes. Check it before the visit, not after the denial.
G0443 is limited to four sessions in 12 months and requires a positive G0442 screen first. Tobacco counseling is limited to two cessation attempts per 12 months with up to four sessions each; the sessions can be any mix of 99406 and 99407, and the count resets after 11 full months. G0447 is the most complicated: Medicare covers one visit a week in the first month, one every other week in months two through six, and one a month in months seven through twelve, but the second six months are covered only if the patient has lost at least 3 kilograms during the first six months, and the weight must be documented. The cap is 22 visits in 12 months, counted together with the group code G0473.
G0136 has a shorter cycle: once every six months. In 2024 and 2025 it was the social determinants of health (SDOH) risk assessment, a 5 to 15 minute standardized screen for food, housing, transportation and similar needs, payable as an optional AWV element with no cost sharing or with an E/M visit with cost sharing. The CY 2026 Physician Fee Schedule final rule, published November 5, 2025, kept the code but revised its descriptor to a standardized, evidence-based physical activity and nutrition assessment, effective January 1, 2026. The mechanics did not change: 5 to 15 minutes, once every six months, an optional element of the AWV, and payable separately with an E/M visit. Practices that built an SDOH screen into the AWV need to review the tool they use against the new descriptor.
Same-day billing with the wellness visit and problem visits
Most of these services are billed on the same day as G0438 or G0439, and that is fine, with one exception worth knowing. The initial AWV (G0438) already includes a review for depression, so G0444 is not separately payable with G0438 in our experience and with most contractors' edits; it is payable with the subsequent AWV (G0439). Alcohol screening, tobacco counseling, G0446 and G0447 can accompany either AWV code when the documentation stands on its own.
"Stands on its own" is the point. The AWV template in most EHRs has a box that says "depression screening: PHQ-2 negative." That satisfies the AWV element. To bill G0444, the note needs the tool, the score and the plan as a distinct service, and the time if the payer asks. We tell practices to give each separately billed preventive service its own labeled paragraph or its own flowsheet row with the minutes.
When a problem-oriented E/M visit happens on the same day as preventive services, modifier 25 goes on the E/M code, not on the G-codes. The counseling time cannot be counted twice: minutes spent on G0446 cardiovascular counseling are not also minutes toward a time-based 99214. Commercial payers that follow the Affordable Care Act preventive rules often want modifier 33 on preventive services to waive cost sharing; Medicare does not use modifier 33 for these codes.
Diagnosis codes that get these paid
Screening services take screening diagnosis codes, and Medicare contractors are particular. The codes we see accepted are Z13.39 (encounter for screening examination for other mental health and behavioral disorders) for G0442 and Z13.31 (encounter for screening for depression) for G0444. G0443 takes the alcohol diagnosis the screen produced, such as F10.10, or Z71.41 for counseling. Tobacco counseling takes F17.210 or another F17 code for current dependence, or Z87.891 for a former user still at risk, with Z71.6 as the counseling code. G0446 uses Z13.6 (encounter for screening for cardiovascular disorders). G0447 needs an obesity diagnosis from E66 plus a Z68.3x or Z68.4x BMI code that shows 30 or higher. Check each contractor's billing article, because a few list specific code sets, and a screening service billed with a treatment diagnosis is the most common cause of a CO-11 (diagnosis inconsistent with procedure) denial on these lines.
A worked subsequent wellness visit
A 71-year-old established patient with hypertension and a 30-year smoking history comes in for a subsequent AWV on March 12, 2026. Her last AWV was March 5, 2025, so more than 11 full months have passed. The eligibility check shows no G0442 or G0444 paid in the last year. The nurse administers the AUDIT-C (negative) and the PHQ-9 (score 4) and documents 5 minutes for each. The physician spends 6 minutes on tobacco cessation counseling and prescribes varenicline, then 15 minutes on cardiovascular risk counseling covering diet, aspirin use and blood pressure goals, documenting the time and the content of each. The patient also mentions worsening knee pain, which the physician evaluates and treats with a plan for imaging.
- G0439, subsequent AWV, with Z00.00.
- G0442 with Z13.39, and G0444 with Z13.31, each with the tool, score and minutes in its own paragraph.
- 99406 with F17.210 and Z71.6, noting 6 minutes.
- G0446 with Z13.6, noting 15 minutes and the topics covered.
- 99213-25 with M17.11 for the knee, supported by a separate problem-focused note.
Using round illustrative allowables, the four preventive add-ons together come to roughly $70 to $90, on top of the AWV and the E/M. Multiply by the number of Medicare AWVs a practice performs in a year and the amount left unbilled in the first practice we described was real money for work it had already done.
Questions we hear
Can the medical assistant do the screenings?
The screening tools can be administered by clinical staff under the physician's supervision, and the service is billed under the physician or non-physician practitioner who reviews the result and directs any follow-up. Counseling codes (G0443, 99406, 99407, G0446, G0447) require the physician or qualified health professional to furnish the counseling personally, face to face. Some of these are also on the Medicare telehealth list, and with flexibilities extended through 2027 they can be furnished by video, but the counseling still has to be the practitioner's own time.
We got a frequency denial and the patient swears nobody screened her. What now?
Pull the eligibility response and look at the last paid date for the code. If another provider billed it within the window, the denial stands and the patient owes nothing; you simply were not eligible to bill that day. If the response shows no prior service, the denial is likely a payer error, and an appeal with the eligibility printout attached usually resolves it. Our denial management team keeps that printout with every preventive claim for exactly this reason.
Should we bill G0136 with every AWV?
Only when a standardized tool that fits the current descriptor is actually administered, the result is reviewed and the time is documented. With the 2026 descriptor change to physical activity and nutrition, a practice still using its 2024 SDOH questionnaire should confirm the tool matches before continuing to bill. Honestly, for most practices the money in this list is in G0442, G0444 and tobacco counseling; start there.
What to do this week
- Run a report of G0438 and G0439 claims for the last six months and list which of G0442, G0444, 99406, 99407, G0446 and G0447 were billed alongside them. The gap is your opportunity.
- Add the eligibility check for preventive service dates to the pre-visit workflow for every Medicare AWV.
- Rebuild the AWV template so each separately billable service has its own labeled section with tool, result and minutes.
- Give the front desk and clinical staff a one-page frequency card with the limits in the table above.
- Review the tool you use for G0136 against the 2026 descriptor and retire it if it no longer fits.
- Consider adding these services to the gaps in care work you already do, since the same visit closes screening measures and pays for them.
