Internal medicine billing services should capture three Medicare services: the Annual Wellness Visit (G0438, G0439), chronic care management (99490, 99439, 99491) and transitional care management (99495, 99496). The usual miss isn’t the code. It’s the prerequisite: the 12-month interval, documented consent, or the two-business-day contact.
AMS has separate deep-dives on each program: AWV billing with modifier 25 and depression screening, the CCM code family step by step, and TCM’s 14-day rule. This post is the overview that ties them together: what each program requires, where each one fails, and how they stack for the same patient. For the wider picture beyond these three programs, see our complete guide to internal medicine billing. All figures are drawn from the CMS Medicare Learning Network (MLN) booklets named below and the CPT descriptors as published by AAPC.
Annual Wellness Visit: Medicare HCPCS codes, not a physical
The AWV is a Medicare benefit billed with HCPCS codes. It is not the CPT preventive medicine visit. CMS’s Medicare Wellness Visits page (last modified 8 April 2026) states plainly that a routine physical exam is not covered and the patient pays 100% out of pocket. The AWV is a different service: a health risk assessment and a personalized prevention plan.
From CMS’s Annual Wellness Visit page (last modified 9 April 2026):
- G0438 is the first AWV and G0439 each subsequent AWV. You can bill either one once in a 12-month period.
- Don’t bill G0438 or G0439 within 12 months of G0402, the Welcome to Medicare exam. CMS denies those claims as having reached the benefit maximum.
- A same-day problem visit is payable when it is a significant, separately identifiable, medically necessary E/M service, reported with modifier 25.
- Advance care planning (99497) can be an optional AWV element. When it is delivered the same day by the same provider and billed with modifier 33 on the AWV claim, CMS waives the patient’s deductible and coinsurance.
- G0136, the physical activity and nutrition risk assessment, is another optional element with the same modifier 33 cost-share waiver when billed with the AWV.
Common misses: scheduling at eleven months and some days instead of twelve full months; billing G0438 to a patient who already had one elsewhere; skipping the health risk assessment; and a template that appends modifier 25 to every AWV-day E/M.
Chronic care management: minutes, consent, one practitioner a month
CPT, as summarized by AAPC (1 May 2025), defines the core codes by who does the work and for how long in a calendar month:
- 99490: first 20 minutes of clinical staff time directed by a physician or other qualified health care professional.
- 99439: each additional 20 minutes of clinical staff time (add-on to 99490).
- 99491: first 30 minutes provided personally by the physician or other qualified health care professional.
- 99437: each additional 30 minutes of physician or QHP time (add-on to 99491).
CMS’s Chronic Care Management Services booklet (MLN909188, June 2025) sets the Medicare requirements:
- Eligibility: two or more chronic conditions expected to last at least 12 months, or until death, that place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.
- Initiating visit: required for new patients or patients not seen in the previous year. It must be a comprehensive E/M visit, an AWV or an IPPE at which CCM is discussed.
- Consent: written or verbal, documented, covering cost sharing, the fact that only one practitioner can bill CCM in a calendar month, and the right to stop.
- Infrastructure: certified EHR, an electronic comprehensive care plan, and 24/7 access to the care team.
Common misses: reporting 99491 in the same month as 99490 or 99439 (CMS says don’t); counting minutes already used for another billed code; no documented consent; and a care plan that exists on paper but was never shared.
Transitional care management: three clocks
CPT’s required elements, per AAPC (1 October 2021):
- 99495: communication with the patient or caregiver within 2 business days of discharge, at least moderate medical decision making, and a face-to-face visit within 14 calendar days.
- 99496: the same 2-business-day contact, high medical decision making, and a face-to-face visit within 7 calendar days.
CMS’s Transitional Care Management Services booklet (MLN908628, August 2025) adds the Medicare rules:
- The 30-day TCM period starts on the day of discharge and runs for the next 29 days.
- Two or more documented, timely, unsuccessful contact attempts can still support the service if the other requirements are met.
- Medication reconciliation must be done on or before the face-to-face visit.
- Only one practitioner may report TCM, once per period. The face-to-face visit can’t be on the same day as discharge day management, and TCM isn’t paid if any of the 30 days falls in the same practitioner’s global surgery period.
- At a minimum, document the discharge date, first contact date, face-to-face date and MDM level.
Common misses: nobody owns the discharge list, so the 2-business-day window closes before anyone calls; and the face-to-face visit gets billed as a separate E/M.
How the three stack
| Service | Codes | Frequency | Can stack with |
|---|---|---|---|
| Annual Wellness Visit | G0438, G0439 | Once per 12 months | Same-day E/M with modifier 25; can be the CCM initiating visit |
| Chronic care management | 99490, 99439, 99491, 99437 | Per calendar month | TCM in the same 30 days (MLN909188), time counted once |
| Transitional care management | 99495, 99496 | Once per 30-day period | CCM in the same period |
Three stacking rules, all from the MLN booklets:
- The AWV can serve as the CCM initiating visit when CCM is discussed at it (MLN909188).
- CCM codes can be reported during the TCM 30-day period. MLN909188 names 99490 and 99491 among them, and MLN908628 allows concurrent care management when time and effort aren’t counted twice.
- Remote monitoring rides with one program at a time. MLN909188 says you can bill either remote physiologic monitoring or remote therapeutic monitoring, but not both, alongside CCM or TCM. See our RPM billing guide for internal medicine.
One more choice to make on purpose: MLN909188 describes Advanced Primary Care Management (G0556, G0557, G0558) as a monthly bundle that includes CCM and TCM elements without minute counting. Decide per patient whether you are running time-based CCM or APCM, and keep the claim history consistent.
A monthly workflow that catches all three
- Daily: pull hospital and SNF discharges and make the TCM contact within 2 business days.
- At scheduling: check the last AWV date through eligibility before booking, not at check-in.
- At every AWV: screen for CCM eligibility and document the CCM conversation and consent.
- Month-end: reconcile CCM time logs against thresholds and make sure no minute is counted twice.
One AMS client, an internal medicine practice in Michigan, cut accounts receivable by almost $300,000 with structured revenue cycle management and same-day denial work. More billing checklists are in our resources library.
If your AWV, CCM and TCM volume doesn’t match your Medicare panel, talk to the team behind our medical billing services, which has been billing for practices since 1992. To see what your AWV, CCM and TCM claims are leaving behind, request a Free Billing Analysis or call 866-973-2221.
