brevaThe personalized prevention plan and what the wellness note must show
Updated October 16, 2026. G0438 and G0439 both end with a personalized prevention plan of service, written and given to the patient. This is what the note needs to document. Confirm with your Medicare Administrative Contractor before you rely on it for a claim.
What a personalized prevention plan is
Medicare's wellness visit is a planning visit. The required output is a written plan for the patient: a screening schedule for the next 5 to 10 years, a list of risk factors and conditions with the interventions recommended or under way, and personalized advice and referrals. It is named in the code descriptions themselves ("including a personalized prevention plan of service"). Source: 42 CFR 410.15.
Documentation checklist, initial visit (G0438)
Each line is an element Medicare lists for the initial visit. A line the note does not show is an element an auditor cannot find.
- Health risk assessment reviewed, and administered if needed, with the date and who completed it
- Medical and surgical history, family history, and current medications and supplements
- Current opioid prescriptions reviewed; substance use disorder screening with the tool and result
- List of current providers and suppliers involved in the patient's care
- Height, weight, body mass index (or waist circumference) and blood pressure
- Cognitive assessment method and findings
- Depression risk review with a standardized tool and its result
- Functional ability and safety: hearing, activities of daily living, fall risk and home safety
- Written screening schedule for the next 5 to 10 years, based on USPSTF and ACIP recommendations and the patient's own risk factors
- List of risk factors and conditions with interventions recommended or under way
- Personalized health advice and referrals, including the education and counseling programs discussed
- Advance care planning, if the patient agreed to it
- A copy of the plan given to the patient
Documentation checklist, subsequent visit (G0439)
The subsequent visit updates rather than re-establishes.
- Health risk assessment updated
- Changes to medical and family history
- Current opioid prescriptions reviewed; substance use disorder screening
- Changes to the provider and supplier list
- Weight (or waist circumference) and blood pressure
- Cognitive assessment
- Screening schedule updated; risk factor and intervention list updated
- Personalized health advice and referrals
- Advance care planning, if the patient agreed to it
Optional elements worth a line
- Physical activity and nutrition assessment (G0136, 5 to 15 minutes with a validated tool) and its result
- Advance care planning time, for 99497 and 99498
- Any separate problem addressed, documented on its own for the modifier 25 office visit
Printable forms you can use
The initial and subsequent Annual Wellness Visit templates carry every line above as a blank field, to copy, download or print. The health risk assessment form covers the questions the patient answers before the visit.
Record the wellness visit in Breva and review the note and its suggested codes before they reach the chart. The Breva scribe.
Read next
G0438 vs G0439. Eligibility and timing. Payment amounts, denial codes and the 2026 telehealth rules are on the Annual Wellness Visit coding reference.