This scenario asks a lot of you: switch from preventive mode to diagnostic mode mid-visit, handle both well, and stay on schedule. Providers who pull that off should be paid for both halves of the work. The scenario happens constantly in primary care: a Medicare patient is scheduled for their Annual Wellness Visit, and during the visit they raise an acute or chronic problem that requires real clinical evaluation. You address it. You should be compensated for it. The question is how to bill it correctly. To be clear about intent: none of this is about charging the patient more. It is about documenting the work accurately so it is recognized. The patient's cost-sharing is set by their plan, not by whether you capture your own credit correctly.

The Short Answer

Yes, you can code both the AWV and a problem-oriented E/M on the same day. You append Modifier 25 to the E/M code to indicate it was a significant, separately identifiable service from the AWV. The patient owes no cost-sharing for the AWV (G0438/G0439), but the E/M is subject to their deductible and cost-sharing, tell them this before the visit ends.

What Is Required for Each Service

For the AWV portion: Document all required AWV components (health risk assessment, prevention plan, medication review, cognitive screening, etc.) as described in Chapter 15. This portion of the note is the AWV.

For the E/M portion: Document the separate clinical problem, the assessment of the new complaint, the data you reviewed, your decision-making, and your plan. This portion must stand independently as a problem-oriented evaluation. It should be clearly separate in your note from the AWV components.

The G2211 Opportunity in 2025

Starting January 1, 2025, G2211 (the longitudinal care add-on, covered in Chapter 8 ) can be coded alongside the Modifier 25 E/M when the same-day service is the AWV. This is one of the specific exceptions CMS carved out. So the full billing for this scenario for a qualifying Medicare patient can include:

All three can be on the same claim when the clinical facts and documentation support them. This combination represents one of the best-reimbursed routine primary care visit patterns available for Medicare patients.

Step by Step: How to Structure the Note

Step 1. Complete and document all required AWV components in a dedicated AWV section of the note.

Step 2. In a separate section, document the acute problem: the complaint, the relevant history, your examination findings, any data reviewed, your assessment, and your plan. Make this section complete enough to stand alone as an E/M note.

Step 3. At the end of the note, if billing by time, document total physician time for the entire encounter. If billing by MDM, ensure the E/M section supports the MDM level you are selecting.

Step 4. Alert the patient (or their family) that an additional charge will appear for the E/M portion.

Step 5. Submit: AWV code + E/M code with Modifier 25 + G2211 (if applicable for your practice type).

Do not add Modifier 25 to the AWV code
Modifier 25 goes on the E/M code, not the AWV code. This is a common technical error that generates claim denials. The modifier signals that the E/M was a separate service from the AWV, it belongs on the E/M line.

When the Patient Brings a Problem to the Wellness Visit

The same wellness visit, but partway through the patient mentions that their knee has been swelling and painful for two weeks. You now do two distinct pieces of work: the wellness visit and a focused evaluation and management of the knee, with its own history, examination, and plan. Both are codable. You report the Annual Wellness Visit and a separate office E/M with Modifier 25 appended, because the problem evaluation was significant and separately identifiable from the wellness work. The documentation has to clearly separate the two: the wellness components in one section, the problem-focused note in another. Done that way, billing both is correct and expected, not aggressive.

Previous GuideGuide 17: Medicare Annual Wellness Visits