What preventive services does Medicare cover?
Quick Answer
Medicare Part B covers a comprehensive set of preventive services at no cost to the beneficiary (no deductible, copay, or coinsurance) when provided by participating providers. Key covered services include: Annual Wellness Visit (G0438 initial ~$175, G0439 subsequent ~$282), Welcome to Medicare Visit (G0402, within first 12 months of Part B), cardiovascular disease screening (lipid panel every 5 years), diabetes screening (fasting glucose or HbA1c for at-risk patients, up to 2 per year), colorectal cancer screening (colonoscopy every 10 years, FIT/FOBT annually, Cologuard every 3 years), mammography (annually for women 40+), lung cancer screening (low-dose CT annually for qualifying patients 50-80), depression screening (PHQ-2/PHQ-9 annually, G0444 ~$18), alcohol misuse screening (G0442 ~$18), obesity counseling (G0447), tobacco cessation counseling (99406/99407), immunizations (flu, pneumococcal, hepatitis B, COVID-19 at no cost), and bone density screening (every 2 years for qualifying women). NPIxray analysis of 1,175,281 Medicare providers shows most practices capture only 30-50% of eligible preventive services, with AWV completion at just 38% nationally, representing substantial missed revenue and quality gaps.
Zero-Copay Preventive Services
Medicare covers specific preventive services with no beneficiary cost sharing when billed with the correct codes and diagnoses. This is a significant advantage for patient outreach since there is no cost barrier. Annual Wellness Visit (G0438/G0439): comprehensive preventive planning visit covered annually at $175-$282. Welcome to Medicare Visit (G0402): one-time preventive visit within the first 12 months of Part B enrollment at approximately $174. Cardiovascular screenings: lipid panel every 5 years, EKG screening (one-time with Welcome to Medicare). Diabetes screening: fasting glucose, HbA1c, or oral glucose tolerance test, up to 2 per year for at-risk patients. Cancer screenings: mammography (annually age 40+), colonoscopy (every 10 years or 4 years if high-risk), FIT/FOBT (annually), Cologuard/stool DNA (every 3 years), cervical/vaginal cancer screening (Pap smear every 2 years, or annually for high-risk), prostate cancer screening (PSA annually for men 50+), lung cancer screening (LDCT annually for ages 50-80 with 20+ pack-year smoking history). All these services generate revenue for the practice while incurring zero patient cost, removing the most common patient objection to scheduling.
Screenings with Separate Billing Codes
Several preventive services are billed as separate encounters or add-ons, each generating incremental revenue. Depression screening (G0444, ~$18): annual PHQ-2/PHQ-9 screening. Can be billed during an AWV or as a standalone service. Positive screens create BHI (99484) enrollment opportunities. Alcohol misuse screening and counseling (G0442/G0443, ~$18/$25): AUDIT-C or CAGE screening annually with brief counseling for positive screens. Obesity screening and counseling (G0447, ~$25): BMI calculation and behavioral counseling for patients with BMI 30+. Up to 22 visits in the first year. Tobacco cessation counseling (99406/99407, ~$14-$28): up to 8 sessions per 12-month period (two cessation attempts with 4 sessions each). Sexually transmitted infection screening: HIV screening (annually for at-risk), hepatitis B and C screening. Abdominal aortic aneurysm screening: one-time ultrasound for men 65-75 with smoking history. When stacked strategically during an AWV, these add-on services can double the encounter revenue from $282 to $400-$600+. NPIxray identifies which add-on services your practice is currently underbilling relative to peers.
Immunizations Covered by Medicare
Medicare covers several immunizations at no cost to beneficiaries. Part B vaccines (no deductible or coinsurance): influenza (annually, typically billed as 90686 + G0008), pneumococcal (PCV20 or PCV15+PPSV23 for adults 65+), hepatitis B (for at-risk patients), and COVID-19 vaccines. Part D vaccines: shingles (Shingrix), Tdap, and other recommended adult vaccines are covered under Part D, which may involve cost sharing depending on the patient's drug plan. For Part B vaccines, practices should bill the vaccine product code plus the administration code. Revenue per flu shot: approximately $20-$30 (vaccine cost + administration). For a practice administering flu vaccines to 150 Medicare patients annually, this generates $3,000-$4,500 in revenue with minimal clinical time investment. Pneumococcal vaccination is particularly important given updated recommendations for PCV20 (Prevnar 20). Practices should identify Medicare patients who have not received the updated pneumococcal vaccine and schedule administration. NPIxray's provider analysis includes immunization patterns where available in the CMS data, helping practices identify vaccination gaps.
Revenue Strategy for Preventive Services
To maximize preventive service revenue, implement three strategies. Strategy 1: AWV as the enrollment engine. The AWV is the highest-revenue preventive service ($175-$282) and serves as the gateway to identifying patients for CCM, BHI, RPM, and additional screenings. Increasing AWV completion from 38% (national average) to 60% for a practice with 200 Medicare patients adds approximately 44 AWVs x $282 = $12,408 in direct revenue, plus downstream program enrollment. Strategy 2: Stack add-on services. During every AWV, perform depression screening (G0444, +$18), alcohol misuse screening (G0442, +$18), and advance care planning (99497, +$86) when appropriate. Train staff to identify tobacco cessation and obesity counseling opportunities. Strategy 3: Close preventive gaps proactively. Run EHR reports to identify patients overdue for mammography, colonoscopy, lung cancer screening, and bone density. Outreach calls to schedule these services generate both preventive revenue and quality metric improvement for MIPS. Many practices find that implementing a dedicated preventive services coordinator (or adding these duties to an existing MA/LPN role) generates a 3-5x return on the staff investment through increased screening volumes, AWV scheduling, and CCM enrollment.
Preventive Services and Quality Reporting
Medicare preventive services directly support MIPS (Merit-based Incentive Payment System) quality reporting, creating a dual financial benefit. Performing preventive services generates fee-for-service revenue AND improves MIPS quality scores, which can yield positive payment adjustments of up to 9% (or negative adjustments of up to -9% for poor performance). Key MIPS quality measures aligned with preventive services: breast cancer screening (mammography), colorectal cancer screening, diabetes HbA1c control, depression screening and follow-up plan, fall risk screening for elderly patients, tobacco use screening and cessation intervention, BMI screening and follow-up, and pneumococcal vaccination status. Practices achieving exceptional MIPS performance can earn additional bonus payments. The alignment between preventive services and quality reporting means every AWV and screening improves both current revenue and future Medicare payment rates. NPIxray's analysis helps quantify the revenue impact of closing preventive service gaps, combining fee-for-service revenue estimates with MIPS payment adjustment projections. For a practice earning $500,000 in Medicare revenue, the difference between a positive and negative MIPS adjustment can be $45,000-$90,000 annually.
Frequently Asked Questions
Do patients pay anything for preventive services?
Most Medicare preventive services have zero copay, coinsurance, or deductible when provided by participating providers and billed with the correct screening diagnosis codes. If a problem is identified and treated during the same visit, cost sharing applies to the treatment portion.
Can I bill an E&M visit on the same day as an AWV?
Yes. If a clinical problem requiring medical decision-making is identified during the AWV, a separate E&M visit (99213-99215) can be billed with modifier 25. The patient will have cost sharing for the E&M portion but not the AWV portion.
How often can Medicare patients get screening colonoscopies?
Every 10 years for average-risk patients, or every 4 years for high-risk patients. If the screening colonoscopy results in polyp removal (becomes diagnostic/therapeutic), it is still covered as a preventive service.
Which vaccines does Medicare Part B cover?
Part B covers flu, pneumococcal, hepatitis B (for at-risk), and COVID-19 vaccines with no cost sharing. Shingles (Shingrix) and Tdap are covered under Part D, which may involve cost sharing.
See Your Practice's Specific Numbers
Enter any NPI number to instantly see missed revenue from E&M coding gaps, CCM, RPM, BHI, and AWV programs — based on real CMS Medicare data.
Scan Your NPI