Can you bill 99395 to Medicare?

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Original Medicare does not cover CPT code 99395 for routine adult preventive visits.

Medicare Coverage Rules for 99395

  • Original Medicare (Parts A & B): Does not cover routine, comprehensive physical exams billed under code 99395 (which is designated for established patients ages 18 to 39). Submitting this code usually results in a non-covered charge denial.
  • Alternative Medicare Codes: Medicare instead covers specific wellness visits, such as the Welcome to Medicare Preventive Visit (G0402) or the Annual Wellness Visit (G0438 or G0439).
  • Medicare Advantage: Some private Medicare Advantage Plans may cover routine physical exams or specific preventive codes depending on the exact policy, but benefits must be verified directly with the plan.

Is CPT code 99396 covered by Medicare for an annual wellness visit?

No, Medicare does not cover CPT code 99396 for an annual wellness visit.

Medicare Billing Codes

  • Medicare does not accept commercial preventive codes like 99396.
  • Use G0438 for an initial Annual Wellness Visit.
  • Use G0439 for subsequent Annual Wellness Visits.
  • Use G0402 for a "Welcome to Medicare" visit in the first year.

Why 99396 Is Not Covered

  • Original Medicare excludes routine physical exams by law.
  • CPT 99396 is a comprehensive preventive medicine code meant for private commercial insurance, not Medicare.
  • Billing Medicare with 99396 leads to automatic claim denials.

How do I bill for a Medicare Annual Wellness Visit?

To bill for a Medicare Annual Wellness Visit (AWV), use the specific HCPCS code corresponding to whether it is the patient's first or a yearly follow-up visit.

1. Select the Correct Billing Code

  • G0438: Initial Annual Wellness Visit. Use this once per lifetime for a patient's first AWV, available after they have been enrolled in Medicare Part B for at least 12 months.
  • G0439: Subsequent Annual Wellness Visit. Use this for yearly follow-up visits once 11 full calendar months have passed since the previous AWV or initial AWV.
  • Note on G0402: This is the "Welcome to Medicare" Initial Preventive Physical Examination (IPPE), which is a separate, once-in-a-lifetime code used only during the first 12 months of Part B enrollment.

2. Include Required Documentation and Diagnoses

  • Diagnosis Code: Report an ICD-10 code for a general adult medical examination, such as Z00.00.
  • Core Elements: Ensure your documentation includes a completed Health Risk Assessment (HRA), updated medical/family history, a current list of providers/suppliers, biometric measurements (height, weight, BMI, blood pressure), and cognitive/depression screenings.
  • Additional Services: You can bill separately for optional services if documented properly, such as Advance Care Planning (99497 for the first 30 minutes) or a Social Determinants of Health (SDOH) risk assessment (G0136).

3. Combining with E/M Services

  • If you perform a medically necessary Evaluation and Management (E/M) service (such as 99213) during the same encounter for a chronic condition, you can bill it alongside the AWV code.
  • Append modifier -25 to the E/M code to indicate that the service is separate and distinct from the routine wellness visit.

What are the billing guidelines for CPT code 99395?

CPT code 99395 is billed for a periodic, comprehensive preventive medicine reevaluation and management visit for an established patient aged 18 to 39 years.

Patient and Visit Criteria

  • Patient Status: Must be an established patient (seen by the provider or same-specialty group within the past 3 years).
  • Age Range: 18 through 39 years old.
  • Visit Type: Routine wellness exam or annual physical without a primary acute or symptom-driven complaint.

Included Services

  • Age- and gender-appropriate comprehensive history and physical examination.
  • Counseling, anticipatory guidance, and risk factor reduction interventions.
  • Ordering of appropriate laboratory or diagnostic procedures.

Coding and Billing Rules

  • Diagnosis Codes: Use primary preventive ICD-10 codes (such as Z00.00 or Z00.01 for general adult medical examinations). Avoid symptom-based or chronic disease primary codes for the preventive line.
  • Medicare Exclusion: Medicare Part B does not cover CPT 99395; use specific HCPCS codes like G0402, G0438, or G0439 instead.
  • Simultaneous Problem Visits: If a significant, separate acute or chronic problem is addressed during the same visit, bill the appropriate outpatient E/M code (99211–99215) alongside 99395 with Modifier -25 appended to the problem-oriented E/M code, supported by distinct documentation.
  • Additional Services: Separate screening tools (like a PHQ-9 using code 96127) or specific interventions (like tobacco cessation counseling 99406) may be billable separately if allowed by the payer.

For a comprehensive breakdown of coding rules, you can review guidelines from resources like Optimantra and Avenue Billing Services.

Does cpt code 99395 need a modifier?

CPT code 99395 does not need a modifier when it is billed alone for a standard, preventive-only routine physical.

When a Modifier Is Used

  • Modifier 25: If the provider also evaluates a separate, significant, and medically necessary problem during the same visit (such as a sick visit or chronic condition management), you bill a separate problem-oriented E/M code (like 99212–99215).
  • Where it goes: Apply Modifier 25 to the problem-oriented E/M code, not to the 99395 preventive code.
  • Documentation: You must clearly document both services separately in the patient chart to justify the dual coding.

CMS Preventive Services Medicare Patients

9 related questions found

Is 99395 covered by Medicare?

Original Medicare does not cover CPT code 99395 for routine adult preventive visits.

Medicare Coverage Rules for 99395

  • Original Medicare (Parts A & B): Does not cover routine, comprehensive physical exams billed under code 99395 (which is designated for established patients ages 18 to 39). Submitting this code usually results in a non-covered charge denial.
  • Alternative Medicare Codes: Medicare instead covers specific wellness visits, such as the Welcome to Medicare Preventive Visit (G0402) or the Annual Wellness Visit (G0438 or G0439).
  • Medicare Advantage: Some private Medicare Advantage Plans may cover routine physical exams or specific preventive codes depending on the exact policy, but benefits must be verified directly with the plan.

What is the CPT code for an annual physical exam for Medicare?

Medicare annual wellness visits use HCPCS/CPT codes G0438 for initial visits and G0439 for subsequent yearly visits.

Medicare Wellness Visit Codes

  • G0402: Initial Preventive Physical Examination (IPPE), or "Welcome to Medicare" visit. Used only within the first 12 months of Medicare Part B enrollment (once-in-a-lifetime).
  • G0438: Initial Annual Wellness Visit. Used after the first 12 months of enrollment for patients who did or did not have an IPPE.
  • G0439: Subsequent Annual Wellness Visit. Used for yearly follow-up visits after the initial AWV.

Common Add-On Codes

  • 99497: Advance care planning (first 30 minutes).
  • 99498: Advance care planning (each additional 30 minutes).
  • G0444: Annual depression screening.

Will Medicare pay for an annual wellness visit?

Medicare Part B covers one Annual Wellness Visit every 12 months for personalized prevention planning.

Cost and Coverage Details

  • Cost: $0 if your doctor or provider accepts Medicare assignment (the Part B deductible and coinsurance do not apply).
  • Eligibility: You qualify after you have had Medicare Part B for at least 12 months. Your first visit cannot happen within the first 12 months of Part B enrollment or during the same year as your "Welcome to Medicare" visit.

What the Visit Includes

  • A Health Risk Assessment questionnaire about your health status and risks.
  • Routine measurements like height, weight, and blood pressure.
  • A review of your medical history, family history, and current prescriptions.
  • Screenings for cognitive impairment and depression.
  • A personalized written prevention plan or screening schedule for the next 5 to 10 years.

What is Not Included

  • Routine physical exams: Original Medicare does not cover routine, hands-on, head-to-toe physical exams.
  • Diagnostic services: If your doctor performs extra tests, lab work, or treats a chronic or new medical issue during the same visit, you may have to pay coinsurance, copays, or meet your deductible for those extra services.

Can you bill 99395 and 99214 together?

Yes, you can bill CPT 99395 and 99214 together if the provider performs a significant, separately identifiable evaluation and management (E/M) service during a routine preventive visit.

Key Billing Rules

  • Modifier 25: Add modifier 25 to the problem-oriented E/M code (99214), not the preventive code (99395). This tells the insurance company that a distinct service occurred.
  • Separate Documentation: The medical record must clearly separate the routine wellness exam from the acute or chronic problem management. Each service needs its own history, exam findings, and medical decision-making (MDM).
  • No Double Dipping: You cannot use the same exam elements or time spent for both the preventive code (99395) and the diagnostic code (99214).

When It Applies

  • The patient comes in for an annual physical (99395) for ages 18–39.
  • The patient brings up a new problem, such as a sprained ankle or high blood pressure, or the doctor finds a chronic condition needing a new treatment plan.
  • The extra work meets the requirements for a level 4 office visit (99214), such as moderate medical decision-making.

What are the CMS guidelines for Medicare annual wellness visits?

The Centers for Medicare & Medicaid Services (CMS) guidelines for Medicare Annual Wellness Visits (AWVs) outline a yearly, preventive patient encounter designed to create or update a personalized prevention plan, distinct from a routine physical exam.

Eligibility and Frequency

  • Initial AWV (G0438): Available to Part B beneficiaries who have had their Part B coverage for more than 12 months, and who have not received an Initial Preventive Physical Examination (IPPE / "Welcome to Medicare" visit) or an initial AWV in the past 12 months.
  • Subsequent AWV (G0439): Available once every 12 months (at least 11–12 months passing) for patients who have already completed their initial AWV.
  • Cost: Covered at $0 out-of-pocket cost (no co-pay or coinsurance) when provided by an eligible clinician accepting assignment.

Initial AWV Core Requirements

  • Health Risk Assessment (HRA): Completed by the patient or provider covering demographics, self-rated health, psychosocial/behavioral risks, and activities of daily living (ADLs/IADLs).
  • Medical and Family History: Documenting past medical/surgical history, family medical history, and a full list of current medications and supplements.
  • Current Providers/Suppliers: Establishing a list of current medical providers and regular suppliers.
  • Routine Measurements: Measuring height, weight, body mass index (BMI) or waist circumference, and blood pressure.
  • Cognitive Function Assessment: Screening for cognitive impairment via direct observation or structured assessment.
  • Depression Screening & Safety: Reviewing risk factors for depression and functional/safety abilities.
  • Personalized Prevention Plan: Establishing a written screening schedule (checklist for the next 5–10 years) and targeted health advice or referrals.

Subsequent AWV Requirements

  • Updates: Updating the HRA, medical/family history, provider list, routine measurements, and the written screening schedule.
  • Reassessments: Assessing cognitive function, reviewing depression risks, and updating intervention lists and personalized health advice.
  • Advance Care Planning: Discussing advance directives optionally at the patient's discretion during initial or subsequent visits.