Is 99397 an E&M code?

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Yes, CPT code 99397 is a preventive medicine evaluation and management code.

Code Details

  • Definition: A periodic comprehensive preventive medicine reevaluation and management service for an established patient aged 65 years and older.
  • Purpose: It covers routine health exams for asymptomatic patients, including age-appropriate history, a physical exam, and health counseling.

Billing Rules

  • Distinction from Office E/M: While it includes "evaluation and management" in its description, it belongs to the preventive medicine code set (99381–99397), rather than standard office/outpatient E/M codes (99202–99215) used for evaluating acute or chronic illnesses.
  • Insurance Coverage: Commercial insurance plans often cover it, but traditional Medicare does not cover CPT 99397 and instead requires specific HCPCS wellness codes like G0438 or G0439.

Can 99397 be billed with 99214?

Yes, CPT code 99397 can be billed with 99214 if the provider performs a significant, separately identifiable problem-oriented evaluation and management (E/M) service during the same encounter.

Essential Billing Rules

  • Append Modifier 25: You must attach modifier -25 to the problem-oriented code (99214) to indicate that the service is distinct and separate from the routine preventive exam (99397). Do not put the modifier on the preventive code.
  • Distinct Documentation: The medical record must feature clear, separate documentation for both services. The documentation for 99214 cannot rely on the elements used for the preventive physical exam. It must address an acute or active chronic problem requiring medical decision-making (MDM) or a specific amount of time.
  • Separate Diagnoses: It is best practice to link distinct ICD-10 diagnostic codes to each service (e.g., a wellness/screening code like Z00.00 for 99397, and specific symptom or chronic disease codes for 99214).
  • Payer Policies: Check individual commercial or Medicare Advantage guidelines, as some payers have strict bundling edits or specific non-coverage rules for same-day preventive and problem-oriented visits. Standard traditional Medicare does not cover CPT 99397 and requires specific G-codes for wellness.

What are the E&M codes for preventive care services?

Preventive care services are primarily reported using CPT codes 99381–99397 for commercial insurance plans, and specific G-codes for Medicare beneficiaries.

Commercial Preventive Medicine CPT Codes

These codes depend on whether the patient is new or established, as well as their age:

  • Infants & Children (Newborn through 17 years):
    • 99381: Initial comprehensive preventive medicine evaluation (infant, under 1 year)
    • 99382: Initial comprehensive evaluation (ages 1–4)
    • 99383: Initial comprehensive evaluation (ages 5–11)
    • 99384: Initial comprehensive evaluation (ages 12–17)
    • 99391: Periodic comprehensive evaluation (infant, under 1 year, established)
    • 99392: Periodic comprehensive evaluation (ages 1–4, established)
    • 99393: Periodic comprehensive evaluation (ages 5–11, established)
    • 99394: Periodic comprehensive evaluation (ages 12–17, established)
  • Adults (18 years and older):
    • 99385: Initial comprehensive preventive evaluation (ages 18–39, new patient)
    • 99386: Initial comprehensive preventive evaluation (ages 40–64, new patient)
    • 99387: Initial comprehensive preventive evaluation (65+ years, new patient)
    • 99395: Periodic comprehensive evaluation (ages 18–39, established patient)
    • 99396: Periodic comprehensive evaluation (ages 40–64, established patient)
    • 99397: Periodic comprehensive evaluation (65+ years, established patient)

Medicare Preventive & Wellness G-Codes

Medicare does not use standard CPT preventive codes for annual wellness physicals, instead requiring specific HCPCS G-codes:

  • G0402: Initial Preventive Physical Examination (IPPE / "Welcome to Medicare" visit)
  • G0438: Annual Wellness Visit (AWV), initial
  • G0439: Annual Wellness Visit (AWV), subsequent

Key Billing Rules

  • Problem-Oriented E/M Interaction: If a significant, separate problem is evaluated and managed during the same preventive visit, a standard office/outpatient E/M code (99202–99215) can be billed alongside the preventive code using Modifier 25.
  • Diagnosis Codes: Claims should always be linked with appropriate preventative ICD-10 Z-codes (such as Z00.00 for a general adult medical examination without abnormal findings) to establish preventive intent. You can review detailed implementation guidelines via the American Medical Association.

What is CPT code 99397 billing guidelines?

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

Core Billing Guidelines

  • Patient Status & Age: The patient must be established (having received professional services from the physician or another physician in the same specialty within the same group practice within the past three years) and be 65 years of age or older.
  • Service Content: Includes a comprehensive age-appropriate history, physical examination, risk factor reduction counseling, and anticipatory guidance/maintenance guidance (such as diet, exercise, and immunizations).
  • Medicare Exclusions: Traditional Medicare Part B does not cover CPT 99397. Submitting 99397 to traditional Medicare results in a denial. Instead, Medicare requires HCPCS codes G0438 (initial annual wellness visit) or G0439 (subsequent annual wellness visit).
  • Commercial & Medicare Advantage Coverage: Reportable for commercial insurance, Medicaid, and select private plans that cover routine annual physical exams.
  • Primary Diagnosis Code: Use an appropriate routine preventive ICD-10 code, most commonly Z00.00 (encounter for general adult medical examination without abnormal findings).
  • Place of Service: Typically billed under office settings (POS 11) or other eligible outpatient locations.
  • Combining with Problem-Oriented E/M Visits: If an acute or chronic problem is addressed during the same visit requiring significant, separate medical decision-making, append Modifier -25 to the problem-oriented E/M code (99202–99215). The preventive service itself should remain distinct in documentation.

Why is Medicare denying 99397?

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.

What is a level 4 office / outpatient visit in medical coding? 99214 & 99204 explained.

9 related questions found

Will Medicare pay for 99397?

Traditional (Original) Medicare does not cover CPT code 99397.

Medicare Rules for CPT 99397

  • Statutory Exclusion: Original Medicare considers routine comprehensive physical exams (represented by CPT codes 99381–99397) to be non-covered services.
  • Instead of 99397: Medicare uses specific HCPCS "G" codes for preventive care. For established patients, providers must use G0438 (Initial Annual Wellness Visit) or G0439 (Subsequent Annual Wellness Visit).
  • The Difference: A Medicare Annual Wellness Visit focuses on creating a personalized prevention plan and reviewing medical history, whereas CPT 99397 covers a traditional, hands-on physical exam.
  • Advance Beneficiary Notice (ABN): If a provider performs a routine physical exam under code 99397 for a traditional Medicare patient, they should issue an ABN Form via CMS letting the patient know Medicare will deny the claim and the patient may be billed directly.

Exceptions

  • Medicare Advantage: Some Medicare Advantage plans may cover routine physical exams using standard CPT codes like 99397, but coverage varies by specific plan. Always check with the specific plan provider beforehand.

What is the difference between CPT code 99396 and 99397?

The primary difference between CPT codes 99396 and 99397 is the age range of the established patient receiving the preventive wellness examination.

CPT Code 99396

  • Age Range: 40 to 64 years old.
  • Patient Type: Established patient (someone who has seen the provider or same medical group within the past 3 years).
  • Purpose: Periodic comprehensive preventive medicine reevaluation and management, including age- and gender-appropriate history, physical exam, counseling, and ordering routine lab or diagnostic procedures.

CPT Code 99397

  • Age Range: 65 years old and older.
  • Patient Type: Established patient.
  • Purpose: Periodic comprehensive preventive medicine reevaluation and management tailored to older adults, including senior-appropriate history, physical exam, risk factor reduction counseling, and diagnostic test ordering. Note that traditional Medicare typically does not cover standard preventive codes like 99397, requiring HCPCS G-codes (like G0439) instead.

Can 99214 and 99396 be billed together?

Yes, CPT code 99214 and CPT code 99396 can be billed together when the provider addresses a significant, separately identifiable problem-oriented service during the same encounter as a routine preventive visit.

According to a consensus among billing professionals on Facebook, both codes are allowed under specific criteria:

Key Billing Rules

  • Modifier 25: You must append Modifier 25 to the problem-oriented E/M code (99214), not to the preventive code (99396). Putting the modifier on the preventive line will cause a claim denial.
  • Separately Identifiable: The medical record must clearly show that the work done for 99214 went beyond the routine screening, counseling, and history of the preventive visit (99396). Examples include evaluating new-onset hypertension or managing a flare-up of a chronic condition.
  • Documentation: The provider's notes must feature a distinct chief complaint and separate medical decision-making (MDM) for the problem being addressed. Minor or incidental complaints do not qualify for dual billing.
  • Payer Policies: Traditional Medicare does not cover 99396 (using Annual Wellness Visit codes instead), and commercial insurance rules vary by carrier. Always check specific payer guidelines.

Can you bill an office visit and a procedure on the same day?

Yes, you can bill an office visit (Evaluation and Management or E/M service) and a procedure on the same day if the visit is a significant, separately identifiable service.

Rules for Same-Day Billing

  • Modifier 25: You must add modifier 25 to the E/M code to show that the office visit was separate from the routine work done for the procedure.
  • Independent Work: The evaluation must go beyond the normal pre-operative and post-operative care that is already included in the procedure fee.
  • Different Diagnoses: You do not need a different diagnosis code for each service, but your medical records must clearly separate the exam from the procedure itself.

Documentation Requirements

  • Clear Notes: Your chart notes must show why the extra evaluation was needed.
  • Medical Decision-Making: The documentation must prove that the doctor made a separate decision or managed a distinct problem during the visit. You can read more about these requirements through the AAPC Knowledge Center.

What is considered an E&M code?

An E&M (Evaluation and Management) code is a five-digit CPT code from the range 99202–99499 used by healthcare providers to bill for cognitive patient evaluations, clinical management, and consultations.

What Counts as an E&M Service

  • Office and outpatient visits for new or established patients.
  • Hospital observation and inpatient care.
  • Emergency department visits.
  • Nursing facility and home or residence services.
  • Preventive medicine, critical care, and care management.

What Is Not an E&M Code

  • Surgical procedures.
  • Radiologic imaging.
  • Diagnostic lab tests.
  • Reason: Procedures and tests require separate, non-E&M specific CPT codes.

How Codes Are Chosen

  • Medical Decision Making (MDM): Based on the complexity of problems addressed, amount of data reviewed, and risk of complications.
  • Total Time: Cumulative time spent by the provider on the encounter date (including chart review and face-to-face discussion).
  • Patient Status: Whether the patient is "new" (has not been seen by the provider or same specialty group in 3 years) or "established".