Screening for mental health at wellness visits

If you're performing routine physicals for patients with Medicare, you may wonder how you'll be compensated for cognitive functioning or depression screening. Find out the answer to this pressing coding question.

A: The Centers for Medicare and Medicaid Services (CMS) Guide to Preventive Services states the initial annual wellness visit (AWV), for which code G0438 is used, should include:

Additionally, CMS states subsequent AWVs, for which code G0439 is used, should include:

For a depression assessment, CMS and the American Medical Association say you can use any appropriate, standardized depression screening tool designed for this purpose and recognized by a national professional medical organization. The results must include a review of current or past experiences with depression or other mood disorders. You may build the testing tool into your electronic health record, but the documentation should show the tool's source in case Medicare requests the medical record documentation. The tool should show the patient's response or lack thereof (in cases where the patient is mentally deficient or unable to answer-for example a patient with dementia).

An American Academy of Family Physicians' (AAFP) article ( says the most widely used and best-validated options in the primary care setting are patient health questionnaires PHQ-9 and PHQ-2. The PHQ-9's nine questions are weighted by frequency and scored. The PHQ-2 has two specific questions: Over the past 2 weeks, has the patient felt down, depressed, or hopeless? and Over the past 2 weeks, has the patient felt little interest or pleasure in doing things?

In response to Medicare's addition of the G0438 and G0439 codes, the AAFP developed a template ( to help you document the different components in the AWV. The depression part includes the questions from the PHQ-2 screening tool. The cognitive functioning assessment asks about mood/affect, appearance, and family member/caregiver input.

The author is a medical consultant based in Indianapolis, Indiana. Do you have a primary care-related coding question you would like to have our experts answer in this column? Send it to

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