Is code 99397 covered by Medicare?

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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.

Can we bill CPT 99397 for Medicare?

No, traditional Medicare Part B does not cover or accept billing for CPT Code 99397, which is a comprehensive preventive medicine evaluation for established patients aged 65 and older.

Medicare Preventive Billing Rules

  • Statutory Exclusion: Traditional Medicare views routine comprehensive physical exams (CPT codes 99381–99397) as non-covered statutory exclusions. Billing 99397 to traditional Medicare results in a claim denial.
  • Correct Codes: Instead of CPT 99397, Medicare requires HCPCS Level II codes for wellness and preventive services:
    • G0438: Initial Annual Wellness Visit (first 12 months past enrollment)
    • G0439: Subsequent Annual Wellness Visit (every 12 months thereafter)
    • G0402: Initial Preventive Physical Examination (IPPE / "Welcome to Medicare" visit, once per lifetime within the first year)
  • Medicare Advantage: Some Medicare Advantage plans might cover CPT 99397, but you must verify coverage with the specific private plan before rendering and billing the service.

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.

How much does Medicare pay for 99397?

Traditional Medicare pays $0 for CPT code 99397.

Traditional Medicare Part B explicitly excludes routine, comprehensive annual physical exams (which fall under CPT codes 99381–99397) from its scope of benefits. If a provider submits code 99397 to traditional Medicare, the claim will be denied, and the patient may be held responsible for 100% of the cost out-of-pocket.

What Medicare Covers Instead

Medicare covers prevention through dedicated wellness codes, which pay 100% of the allowed amount (leaving the patient with a $0 copay and $0 deductible):

  • G0438: Initial Annual Wellness Visit (reimburses an average of ~$160–$175 depending on geography).
  • G0439: Subsequent Annual Wellness Visit (reimburses a slightly lower national average).

Note: Medicare wellness visits (G-codes) focus on health risk assessments and personalized prevention planning rather than a traditional head-to-toe physical examination.

Exceptions and Commercial Payers

  • Medicare Advantage (Part C): Unlike traditional Medicare, some private Medicare Advantage plans (such as certain UnitedHealthcare Medicare Advantage or Blue Cross Blue Shield products) do choose to cover routine physicals using CPT 99397. Coverage varies strictly by the specific plan's contract.
  • Commercial Insurance: Standard commercial insurance plans (non-Medicare) regularly cover 99397, typically reimbursing providers a national average of $120 to $185.

How often can a CPT 99397 be billed?

CPT code 99397 can typically be billed once per calendar year (or once every 12 months) for an established patient aged 65 and older, depending on the specific commercial or Medicaid payer guidelines.

Key Billing Rules and Frequency

  • Payer Restrictions: This code applies to commercial insurance and Medicaid plans. Traditional, original Medicare excludes codes 99381–99397 and requires HCPCS codes like G0439 for annual wellness visits.
  • Patient Status: The patient must be an established patient (seen by the provider or another physician in the same specialty within the same practice group within the past 3 years) and must be 65 years of age or older.
  • Service Focus: The visit must be strictly preventive. If an acute or chronic issue is managed during the same encounter, a separate evaluation and management (E/M) code with modifier -25 is typically required.

Medicare AWV CPT Codes 2026 Update | Annual Wellness Visit Billing & Coding Guide

9 related questions found

Is CPT code 99397 a physical exam?

Yes, CPT Code 99397 is a code for a periodic comprehensive preventive medicine physical exam.

Key Details About CPT 99397

  • Patient Age: Applies to established patients who are 65 years old and older.
  • Patient Status: Meant for an established patient (someone who has seen the provider or another provider in the same practice within the past three years).
  • Service Scope: Includes an age- and gender-appropriate physical examination, medical history, risk factor screening, health counseling, and ordering routine lab or diagnostic procedures.

Important Billing Rules

  • Commercial vs. Medicare: This code is widely used for commercial insurance and Medicaid plans.
  • Medicare Exclusion: Original Medicare does not cover routine annual physical exams using CPT 99397. Instead, Medicare requires specific HCPCS codes for wellness visits (such as G0438 or G0439), which focus on prevention planning and risk assessment rather than a head-to-toe physical exam.

Does Medicare Advantage cover 99397?

You can bill CPT code 99397 to some Medicare Advantage plans, but coverage depends entirely on the specific contract and plan guidelines.

Coverage Rules

  • Original Medicare: Traditional Medicare Part B strictly excludes routine physical exams and CPT codes 99381–99397, requiring HCPCS codes like G0438 and G0439 for Annual Wellness Visits instead.
  • Medicare Advantage (Part C): Private insurers offering Medicare Advantage may include enhanced preventive benefits that cover CPT 99397.
  • Mixed Opinions: Discussions on platforms like Facebook show that while some Medicare Advantage providers (such as select UnitedHealthcare plans) reimburse for 99397, other plans reject it or require standard Medicare G-codes.

Best Practices for Billing

  • Verify Eligibility: Always contact the specific Medicare Advantage plan before the date of service to confirm if comprehensive preventive codes are part of the patient's supplemental benefits.
  • Check Age Limits: Ensure the patient is an established patient aged 65 or older on the exact date of service.
  • Review Documentation: Make sure the clinical note clearly outlines a comprehensive preventive evaluation rather than a standard Medicare wellness checklist.

Is the CPT code 99397 payable by Medicare?

No, traditional Medicare Part B does not pay for or cover CPT code 99397.

Medicare Billing Rules for 99397

  • Statutory Exclusion: Routine comprehensive physical exams and preventive evaluation codes (CPT 99381–99397) are excluded by law under original Medicare.
  • Alternative Codes: For Medicare patients, you must use HCPCS codes instead of CPT 99397. Use G0438 for an initial Annual Wellness Visit or G0439 for subsequent Annual Wellness Visits.
  • Difference in Service: CPT 99397 requires a full physical exam, whereas Medicare's Annual Wellness Visit focuses on prevention planning, medical history, and risk assessment without a physical exam.
  • Patient Financial Responsibility: Because the service is statutorily excluded, the patient is responsible for 100% of the cost if CPT 99397 is performed and billed to traditional Medicare. Medicare encourages providing an Advance Beneficiary Notice (ABN), though it is not strictly mandatory for statutory exclusions.
  • Medicare Advantage: Some private Medicare Advantage plans may cover preventive CPT codes, but you must verify coverage with the specific plan 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.

What are the 5 treatments that Medicare won't cover?

Original Medicare does not cover several major healthcare services, most notably routine dental care, hearing aids, routine vision care, long-term custodial care, and overseas medical care.

Major Uncovered Services

  • Routine Dental Care: Original Medicare does not pay for routine cleanings, fillings, tooth extractions, root canals, or dentures, except in rare surgical circumstances related to specific medical treatments.
  • Hearing Aids: Routine hearing tests, hearing aid fittings, and the devices themselves are completely excluded under traditional Medicare.
  • Routine Vision Care: Regular eye exams for prescription glasses, as well as contact lenses and eyeglasses, are not covered (aside from standard lenses after cataract surgery).
  • Long-Term Care: Ongoing custodial care—such as daily help with bathing, dressing, eating, or long-term nursing home stays—is not covered, as Medicare only pays for short-term skilled nursing rehabilitation.
  • Care Outside the United States: Medical treatments and services received while traveling internationally are generally not covered.