Is 99397 CPT code denied by Medicare?
Asked by: Natalia Huels | Last update: October 11, 2025Score: 4.3/5 (56 votes)
Why is Medicare denying 99397?
A: The commercial Health Maintenance visit codes (99381-99397) include a pelvic and breast exam. It is assuredly part of the 'age and gender appropriate' physical exam. Medicare, which doesn't pay for the above codes, recognizes the G0101, Q0091 as their AWV visits. The G0439, etc.
What preventive services are not covered by Medicare?
- Eye exams (for prescription eyeglasses)
- Long-term care.
- Cosmetic surgery.
- Massage therapy.
- Routine physical exams.
- Hearing aids and exams for fitting them.
Can 99397 and G0439 be billed together Medicare?
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.
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.
Medicare denial code
Does Medicare Advantage pay for 99397?
They may also offer additional benefits, such as vision, hearing, dental, or health and wellness programs. Some Medicare Advantage plans also cover preventive medicine visits (CPT codes 99381-99397), while traditional Medicare does not. Most Medicare Advantage plans include Medicare prescription drug coverage, Part D.
Does Medicare pay for preventive visits?
Medicare pays for many preventive services to keep you healthy.
What is CPT code 99397 billing guidelines?
CPT code 99397 designates a comprehensive preventive medicine evaluation and management service for established patients, emphasizing the in-depth assessment involved in preventive care.
Why am I being charged for preventive care?
Although you don't pay cost-sharing charges when you receive preventive care, the cost of those services is wrapped into the cost of your health insurance. Thus, whether or not you choose to get the recommended preventive care, you're paying for it through the cost of your health insurance premiums anyway.
What is the age limit for CPT code 99397?
The provider performs an established well–patient visit for a patient who is 65 years or older.
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.
What is not covered by Medicare in Canada?
The Canada Health Act does not cover prescription drugs, home care, or long-term care or dental care. Provinces provide partial coverage for children, those living in poverty, and seniors. Programs vary by province.
What is a common reason for Medicare coverage to be denied?
Many denials are due to reasons such as not meeting medical necessity; frequency limitations; and even basic coding mistakes. Denials are subject to Appeal, since a denial is a payment determination.
Can 99397 be billed as telehealth?
Providers may only bill one preventive medicine code (99381-99387, 99391-99397) to cover both the portion done via telehealth and any necessary face-to-face interaction associated with the preventive care service. Codes for diagnostic services may be separately billed per standard coding guidelines.
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.
Which of the following is not covered by Medicare?
Generally, most vision, dental and hearing services are not covered by Medicare Parts A and B. Other services not covered by Medicare Parts A and B include: Routine physical exams. Cosmetic surgery.
Why did my insurance not cover my doctor visit?
In some cases, the service simply isn't covered by the plan. In other cases, necessary prior authorization wasn't obtained, the provider wasn't in-network, or the claim was coded incorrectly.
Do insurance companies have to cover preventive care?
Most health plans must cover a set of preventive services — like shots and screening tests — at no cost to you. This includes plans available through the Health Insurance Marketplace ®. These services are free only when delivered by a doctor or other provider in your plan's network.
Can an office visit and preventive visit be billed together?
CPT states that if a new or existing problem is assessed and managed at the time of the preventive visit, the physician should also bill a problem-oriented visit (an office visit) on the day of the preventive care.
Does CMS cover 99397?
A physician is not required to give a Medicare beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit not covered by Medicare such as comprehensive preventive Medicine evaluation and management services in the CPT code range 99381-99397.
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.
How to code a preventive visit?
Preventive visit codes 99381-99397 include “counseling/anticipatory guidance/risk factor reduction interventions,” according to CPT. However, when such counseling is provided as part of a separate problem-oriented encounter, it may be billed using preventive medicine codes 99401-99409.
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).
Did Medicare introduce preventive care at no cost?
Prevention and Wellness in Medicare and Medicaid: The Affordable Care Act also provides for prevention without cost-sharing under Medicare.
Why am I getting billed for preventive care?
If you schedule a preventive care visit and ask your doctor about a specific health concern or condition, your clinic may code and bill the appointment as an office visit. If you want to know about costs, ask your doctor for an estimate of fees before you visit.