Is CPT code 99396 covered by Medicare?

Asked by: Josiah Legros  |  Last update: November 29, 2025
Score: 4.2/5 (51 votes)

Original (traditional) Medicare does not cover CPT codes 99381-99397, because Medicare has its own wellness visits with their own “G” codes and requirements. As mentioned, some Medicare Advantage plans do cover the preventive medicine CPT codes in addition to Medicare wellness visits.

Does Medicare pay for procedure code 99396?

As of January 1, 2021, CPT codes 99386 and 99396 will not be paid and will be denied.

Does Medicare cover routine yearly preventive physical examinations?

While Medicare does not cover annual physical exams, it does cover a single "initial preventive physical examination," or IPPE, followed by exams called "annual wellness visits," or AWVs.

What CPT codes are not covered by Medicare?

Certain services are never considered for payment by Medicare. These include preventive examinations represented by CPT codes 99381-99397. Medicare only covers three immunizations (influenza, pneumonia, and hepatitis B) as prophylactic physician services.

Are preventive services free for Medicare patients?

Medicare pays for many preventive services to keep you healthy. For example, if you have Medicare Part B (Medical Insurance), you can get a yearly “Wellness” visit and many other covered preventive services, like colorectal cancer screenings and mammograms.

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41 related questions found

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 are the guidelines for 99396?

The billing guidelines for CPT Code 99396 include documenting medical necessity, accurately documenting the time spent during the visit, using appropriate modifiers for separate services, and obtaining consent or advance beneficiary notice (ABN) if applicable.

What DME is not covered by Medicare?

What kind of equipment does Medicare not cover? Examples: wheelchairs, walkers, hospital beds, power scooters, portable oxygen equipment, orthotics, prosthetics, certain diabetes supplies.

What 5 treatments does Medicare not cover?

Some of the items and services Medicare doesn't cover include:
  • Eye exams (for prescription eyeglasses)
  • Long-term care.
  • Cosmetic surgery.
  • Massage therapy.
  • Routine physical exams.
  • Hearing aids and exams for fitting them.

Is 99397 covered by Medicare?

Traditional Medicare does not pay for routine services reported with codes 99381-99397.

Why doesn't Medicare pay for annual physicals?

Annual physicals aren't covered by traditional Medicare because they are excluded by the federal law that governs Medicare. All Medicare plans cover a Welcome to Medicare exam during your first 12 months with Medicare and in subsequent years, an annual wellness exam.

Does Medicare cover routine yearly blood work?

Does Medicare Offer Coverage for Routine Blood Work? Medicare fully covers only medically necessary blood work. This means a doctor orders the test because they are trying to make a diagnosis. Routine blood work (such as a cholesterol check at an annual physical) is not covered.

What is not covered in a Medicare annual wellness visit?

Medicare does not cover Annual Wellness Visits if they are used to discuss, plan, or alter treatment for pre-diagnosed chronic illnesses, including high cholesterol, high blood pressure, or arthritis.

How to bill Medicare for an annual gyn exam?

For Medicare Advantage, the CPT codes for well woman exams include:
  1. G0403 for the Initial Preventive Physical Exam (IPPE).
  2. G0438 for the first Annual Wellness Visit (AWV).
  3. G0439 for subsequent AWVs.
  4. G0101 for cervical or vaginal cancer screening and clinical breast exams.

What modifier is used for 99396?

In this case, you may submit codes for both a preventive service (such as 99396) and a regular office visit (such as 99213) by attaching -25 to the office-visit code.

Do Medicare wellness visits need to be 12 months apart?

Medicare provides coverage of an Annual Wellness Visit (AWV) for a beneficiary who is no longer within 12 months after the effective date of his or her first Medicare Part B coverage period and who has not received either an Initial Preventive Physical Exam (IPPE) or an AWV within the past 12 months.

What does Medicare no longer cover?

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.

How can I find out if Medicare will cover a procedure?

2 ways to find out if Medicare covers what you need:
  1. Talk to your doctor about why you need certain services or supplies. Ask if Medicare will cover them. What happens if Medicare won't cover a service I need?
  2. Check coverage information on your item, service, or supply.

Does Medicare limit doctor visits?

Medicare does not limit the number of times a person can consult their doctor, but it may limit how often they can have a particular test and access other services. Individuals can contact Medicare directly at 800-MEDICARE (800-633-4227) to discuss physician coverage in further detail.

What DME is reimbursable by Medicare?

Medicare Part B covers medically necessary equipment, devices, and supplies falling under several benefit categories defined under section 1861 of the Social Security Act, commonly referred to as DMEPOS: DME (such as hospital beds, wheelchairs, ventilators, and oxygen equipment)

What percentage does Medicare pay for DME?

Monthly payments for frequently serviced items, like ventilators, are made as long as the equipment is medically necessary. You pay 20% of the Medicare-approved amount after you pay your Part B deductible for the year. Medicare pays the other 80%. The supplier will pick up the equipment when you no longer need it.

Do I own my oxygen concentrator after 5 years?

You'll pay 20% of the Medicare-approved amount for these deliveries. The supplier that delivers this equipment to you in the last month of the 36-month rental period must provide these items, as long as you medically need them, up to 5 years. The supplier owns the equipment during the entire 5-year period.

What age is 99396 for?

The second most commonly used CPT code was 99396, a preventative visit for an established patient between 40 and 60 years of age.

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 difference between 99396 and 99395?

99395: preventive care for established patients ages 18 through 39. 99396: preventive care for established patients ages 40 through 64.