Can 99396 be billed to Medicare?
Asked by: Dr. Nat Johns II | Last update: October 19, 2025Score: 4.8/5 (10 votes)
Is CPT code 99396 covered by Medicare?
We bill Medicare and MCR Advantage plans the Annual Wellness Visit codes G0438 and G0439. We never use 99396 or 99397 for Medicare/MCR Advantage, because they are not a covered code.
Can you bill a preventive visit to Medicare?
Requirements and components for G0402 include: Billable for the IPPE only. Patients are only eligible if they are in their first 12 months of Medicare Part B coverage. Medicare pays for one IPPE per beneficiary, per lifetime.
Can you bill 99396 and G0439 together?
Don't bill CPT codes 99381-99397 (comprehensive preventive medicine evaluation and management services) for Medicare services covered by HCPCS codes G0402, G0438, and G0439.
Are preventive services covered by Medicare?
Medicare pays for many preventive services to keep you healthy. For example, if you have Medicare Part B (Medical Insurance), you can get a yearly “Wellness” visit and many other covered preventive services, like colorectal cancer screenings and mammograms.
BILLING TIPS ON WELCOME TO MEDICARE VISIT AND ANNUAL WELLNESS VISIT
What are 3 services not covered by Medicare?
We don't cover these routine items and services: Routine or annual physical checkups (visit Medicare Wellness Visits to learn about exceptions). exams required by third parties, like insurance companies, businesses, or government agencies. Eye exams for prescribing, fitting, or changing eyeglasses.
How to bill 99396?
The billing guidelines for CPT Code 99396 include documenting medical necessity, accurately documenting the time spent during the visit, using appropriate modifiers for separate services, and obtaining consent or advance beneficiary notice (ABN) if applicable.
How to bill Medicare for an annual gyn exam?
- G0403 for the Initial Preventive Physical Exam (IPPE).
- G0438 for the first Annual Wellness Visit (AWV).
- G0439 for subsequent AWVs.
- G0101 for cervical or vaginal cancer screening and clinical breast exams.
Do Medicare wellness visits need to be 12 months apart?
Medicare provides coverage of an Annual Wellness Visit (AWV) for a beneficiary who is no longer within 12 months after the effective date of his or her first Medicare Part B coverage period and who has not received either an Initial Preventive Physical Exam (IPPE) or an AWV within the past 12 months.
Can 99397 be billed to Medicare?
At the same encounter, the patient chooses to receive a preventive medicine examination (e.g., 99397), which is a non-covered service under Medicare.
Can you bill 99213 and 99396 together?
In this case, you may submit codes for both a preventive service (such as 99396) and a regular office visit (such as 99213) by attaching -25 to the office-visit code.
Does Medicare pay for an annual wellness visit?
AWVs are fully covered by Medicare. Once a patient has been enrolled in Medicare Part B for over a year, they are eligible to receive an AWV once every twelve months. If they've been enrolled in Medicare for less than a year, they can receive a “Welcome to Medicare” visit instead.
What modifier is not accepted by Medicare?
GZ - Service is not covered by Medicare
The GZ modifier identifies that 1) an item or service is expected to be denied as not reasonable and necessary, and 2) no advance notice of non-coverage was supplied to the member.
What is the difference between 99396 and 99395?
99395: preventive care for established patients ages 18 through 39. 99396: preventive care for established patients ages 40 through 64.
What is the CPT code for preventive visit Medicare?
G0402: This code applies to the Welcome to Medicare visit — also referred to as an Initial Preventive Physical Exam (IPPE).
What age is 99396 for?
The second most commonly used CPT code was 99396, a preventative visit for an established patient between 40 and 60 years of age.
Can I refuse the Medicare annual wellness visit?
People can refuse a Medicare annual wellness visit, but it is worth considering the potential benefits. Wellness visits can help healthcare professionals detect health issues early on and are an important part of preventive care.
Why doesn't Medicare pay for annual physicals?
Annual physicals aren't covered by traditional Medicare because they are excluded by the federal law that governs Medicare. All Medicare plans cover a Welcome to Medicare exam during your first 12 months with Medicare and in subsequent years, an annual wellness exam.
Who can bill for a Medicare annual wellness visit?
Billing. Part B covers an AWV if performed by a: Physician (doctor of medicine or osteopathy) Qualified non-physician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist)
Does 99396 include pap smear?
If the patient presents for a preventive medicine service, the pelvic exam is part of the age and gender-appropriate physical exam, as described by CPT® codes in the 99381—99397 series of codes. However, for a screening pap, the HCPCS code for obtaining the screening pap smear, Q0091 may be used.
How often does Medicare pay for gynecological exams?
Pelvic exam
Medicare covers these screening tests once every 24 months in most cases. If you're at high risk for cervical or vaginal cancer, or if you're of child-bearing age and had an abnormal Pap test in the past 36 months, Medicare covers these screening tests once every 12 months.
What is not covered in a Medicare annual wellness visit?
Annual Wellness Visits do not include: A physical exam. Diagnosing of new conditions. Treatment of existing or new conditions.
Can you bill a 99396 to Medicare?
Original (traditional) Medicare does not cover CPT codes 99381-99397, because Medicare has its own wellness visits with their own “G” codes and requirements. As mentioned, some Medicare Advantage plans do cover the preventive medicine CPT codes in addition to Medicare wellness visits.
How to bill Medicare for annual gyn exam?
MEDICARE BILLING FOR WELL-WOMAN EXAMS
If a patient requests a routine health exam rather than a “Welcome to Medicare” visit (G0402) or an annual wellness visit (AWV) (G0438 - G0439), report a preventive medicine code (99381 - 99397) with modifier GY to indicate that the service is not covered by Medicare.
Can 99396 be billed as telehealth?
Comprehensive prevention family planning visits are also covered via telemedicine/telehealth, billed with an FP modifier: CPT® 99384, 99385, 99386, 99394, 99395, 99396, 99401. Comprehensive prevention family planning visits will continue to be limited to once every 365 days.