Annual Wellness Visit billing is one of the most frequently miscoded service lines in primary care. We surface frequency violations, missing documentation elements, and modifier errors before a Palmetto GBA inquiry forces them to surface during enforcement.
Every practice we audit shows exposure in at least one of these three. Most show exposure in two. The patterns are predictable, which is exactly why the OIG has placed AWV billing on the Work Plan in recent cycles — and why a structured audit before a contractor inquiry is the lowest-cost way to surface the risk.
G0438 billed twice on the same patient. G0439 inside the 12-month window. Lifetime cap and annual frequency are both objective rules — the audit math doesn't bend, and recoupment is straightforward when surfaced on review.
HRA not completed. Depression screen not documented. Cognitive assessment, fall risk, or ACP missing from the encounter note. Each missing element renders the AWV non-payable on retrospective review under 42 CFR 410.15.
Modifier 25 missing on an E/M billed alongside the AWV same date. Modifier 33 missing on ACP. Preventive codes 99381–99397 billed to Medicare. G0444 billed inside the initial AWV bundling window. Small details, real exposure.
Five categories of compliance review across the engagement. Each finding is risk-tiered (HIGH / MEDIUM / LOW), cited to the controlling regulation or LCD, and quantified for dollar exposure where calculable.
| Category | What we test |
|---|---|
| Frequency violations | G0438 lifetime cap · G0439 12-month window · duplicate billing inside frequency rules |
| Documentation elements | HRA completion · depression screen · cognitive assessment · fall risk assessment · advance care planning |
| Modifier accuracy | Modifier 25 on E/M billed with AWV · Modifier 33 on ACP for no-cost-share to beneficiary |
| CPT misuse | Preventive codes 99381–99397 billed to Medicare · G0468 place-of-service mismatches · G0444 bundling inside the initial AWV window |
| Provider-level patterns | Systemic finding flag when a single provider drives ≥3 instances of the same exception — pattern exposure calculation applied |
No-PHI default architecture. Claims data is processed in memory and never written to disk during automated review. A Business Associate Agreement is executed before any PHI exchange. Standard turnaround is five business days from intake receipt for the deliverable-only tier; the engagement tier adds a 30-minute findings debrief call within seven business days of delivery.
BAA executed if needed. Secure file transfer setup. Claims CSV intake template returned.
Five-category audit run end-to-end. Findings risk-tiered against rubric and cited to controlling regulation.
Dollar exposure quantified per finding. OIG 2026 Work Plan items mapped. Corrective actions ranked by impact.
Branded PDF report and 7-tab Excel workbook delivered. Engagement tier adds a 30-minute debrief call.
Productized pricing. Flat fees, no hourly billing, no surprise scope expansion. Larger claim volumes or full-spectrum compliance reviews are available as engagement-based scoping — start with the discovery call.
For practices that want the findings and will run their own corrective action.
For practices preparing for a contractor inquiry, an ownership change, or a new compliance officer.
A 20-minute discovery call covers your AWV billing posture, the engagement tier that fits, and the intake timeline. No commitment to engage; the call alone is often useful.