Can 99397 and G0402 be billed together?

No, you cannot bill HCPCS code G0402 (Initial Preventive Physical Examination/Welcome to Medicare visit) and CPT code 99397 (preventive visit for an established patient aged 65 and older) together for traditional Medicare patients.

Billing Rules and Payer Guidelines

• Statutory Exclusion: Traditional Medicare statutorily excludes commercial preventive medicine codes like CPT 99397.
• Exclusive Coding: According to CMS Guidelines, Medicare requires specific G-codes (G0402, G0438, G0439) for wellness and preventive exams and prohibits billing the 99381–99397 CPT series for these services.
• Commercial vs. Medicare: Code 99397 is reserved for commercial insurance or specific Medicare Advantage plans that explicitly cover routine CPT physicals alongside or instead of Medicare G-codes

No, you cannot bill CPT code 99397 and HCPCS code G0439 together for traditional Medicare patients.

Why They Cannot Be Billed Together

• Medicare Rules: Original Medicare does not cover routine physical exams like 99397 (comprehensive preventive medicine for patients 65 and older).
• The Correct Code: Medicare instead requires the Annual Wellness Visit code G0439.
• No Double Billing: According to the CMS Medicare Claims Processing Manual, you should not bill CPT preventive codes 99381–99397 for services covered by Medicare's G-codes. Doing so will result in a claim denial.

Exceptions

• Commercial and Advantage Plans: If the patient has a commercial insurance plan or a specific Medicare Advantage plan that covers routine annual physicals, 99397 might be allowed alongside other services.
• Verification: Always check the specific payer's guidelines and verify patient benefits before combining or submitting these codes. You can discuss specific scenarios further in forums like the AAPC Medical Billing and Coding Forum.

HCPCS code G0402 represents the Initial Preventive Physical Examination (IPPE), commonly known as the "Welcome to Medicare" preventive visit.

Key Billing and Coverage Rules

• Timeframe: Must be performed within the first 12 months of the patient’s initial Medicare Part B enrollment.
• Frequency: Limited to once per lifetime.
• Provider Requirements: Must be furnished and billed by an authorized physician or qualified non-physician practitioner (such as a nurse practitioner, physician assistant, or clinical nurse specialist).
• Exclusions: It is a consultation and evaluation service, not an extensive, head-to-toe physical examination. It also excludes routine laboratory tests.
• Simultaneous E/M Services: If a significant, separate problem-oriented Evaluation and Management (E/M) service (codes 99212–99214) is performed during the same encounter, it may be billed separately by appending modifier -25 to the E/M code.
• Electrocardiogram (ECG): A screening ECG is not automatically bundled into G0402; if ordered/performed, it must be billed separately using code G0403, G0404, or G0405 with an explicit referral.

Medicare denies CPT code 99397 because routine comprehensive physical exams for adults are a Statutory Exclusion under traditional Medicare benefit rules.

Why Traditional Medicare Denies 99397

• Statutory Exclusion: Traditional Medicare Part B does not cover CPT codes 99381 through 99397 for periodic comprehensive preventive medicine. No appeal can overturn this denial because it is excluded by law.
• Incorrect Code Set: Medicare requires specific HCPCS codes instead of CPT preventive codes for wellness exams.

Correct Coding for Medicare Patients

• Initial Visit: Use HCPCS code G0438 for an initial Annual Wellness Visit (AWV).
• Subsequent Visits: Use HCPCS code G0439 for annual wellness visits in later years.
• Initial Exam: Use HCPCS code G0402 for a "Welcome to Medicare" physical during the first 12 months of enrollment.

CPT code 99397 is used to bill for a periodic comprehensive preventive medicine reevaluation and management service for an established patient aged 65 and older.

Core Billing Rules & Guidelines

• Patient Status & Age: Applies strictly to established patients who are 65 years of age or older.
• Service Content: Includes an age- and gender-appropriate comprehensive history, a physical examination, risk factor screening, and health counseling/anticipatory guidance (such as diet, exercise, and fall prevention).
• Medicare Policy: Do not bill 99397 to Medicare. Medicare does not cover routine physical checkups under these CPT codes and instead requires HCPCS codes like G0438 (initial annual wellness visit) or G0439 (subsequent annual wellness visit). Review the CMS Manual System guidelines for further details on wellness billing.
• Commercial & Medicaid Payers: Generally accepted by commercial insurance and Medicaid plans for annual preventive exams.
• ICD-10 Diagnosis: Typically billed with a routine preventive diagnosis code, such as Z00.00 (encounter for general adult medical examination without abnormal findings).
• Combining with Sick Visits: If a significant, separate acute or chronic problem is addressed during the same visit, you can report a problem-oriented E/M code alongside 99397 by appending modifier -25 to the E/M code. The clinical documentation must clearly separate the preventive service from the problem-oriented work.
• Labs and Diagnostic Tests: Routine screening tests and laboratory work ordered during the encounter are coded and billed separately.