What is the age limit for CPT code 99397?

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CPT code 99397 applies to established patients who are 65 years of age and older.

Key Details

  • Patient Status: Must be an established patient (meaning they have received professional services from the physician or another physician of the same specialty in the same group within the past three years).
  • Service Type: A periodic comprehensive preventive medicine evaluation and reevaluation.
  • Lower Age Limit Boundary: The patient must be at least 65 years old on the exact date of service; patients aged 40 through 64 use CPT code 99396.

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 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.

Is code 99397 covered under Medicare?

Traditional Medicare Part B does not cover CPT code 99397.

Medicare Coverage Rules

  • Statutory Exclusion: Routine physical examinations and comprehensive preventive evaluation codes (CPT 99381–99397) are excluded from coverage under traditional Medicare.
  • Correct Billing Codes: Medicare uses its own HCPCS Level II G-codes instead of CPT 99397 for annual wellness services. For established patients, use G0438 (initial annual wellness visit) or G0439 (subsequent annual wellness visit).
  • Medicare Advantage: Some Medicare Advantage plans may cover CPT 99397, but you must verify benefits directly with the specific plan provider.

Financial Responsibility

  • If billed to traditional Medicare, code 99397 will result in a denial, and the patient is fully responsible for the cost.
  • You can check current billing guidelines and updates through the CMS Claims Processing Manual.

What is the age range for CPT?

In medical billing, Current Procedural Terminology (CPT) age ranges depend on the specific service provided and the patient's exact age on the date of service.

If you are instead referring to the psychological assessment tool—the Continuous Performance Test (CPT)—it evaluates attention in individuals aged 4 and older.

Medical Billing & Preventive Care CPT Age Bands

For routine pediatric and adult preventive evaluation and management (E/M) visits, CPT codes (such as those found through the AAPC Code Database) use strict, non-overlapping age breakdowns:

  • Infants (Under 1 year): Codes 99381 (new) and 99391 (established)
  • Early Childhood (1 to 4 years): Codes 99382 (new) and 99392 (established)
  • Late Childhood (5 to 11 years): Codes 99383 (new) and 99393 (established)
  • Adolescent (12 to 17 years): Codes 99384 (new) and 99394 (established)
  • Young Adult (18 to 39 years): Codes 99385 (new) and 99395 (established)

Note: Transitioning between codes happens precisely on the birthday. For example, a patient shifts from early childhood codes to late childhood codes on their 5th birthday, regardless of previous visit patterns.

Continuous Performance Test (CPT) Age Ranges

If your question is about the neuropsychological test for attention and ADHD (like the Conners CPT Suite):

  • Conners K-CPT 2: Ages 4 to 7 years (shorter version, ~7.5 minutes)
  • Conners CPT 3 & CATA: Ages 8 years and older (~14 minutes)

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

9 related questions found

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.

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 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.

Can you bill 99214 and 99397 together?

Yes, CPT code 99397 (preventive visit for an established patient aged 65 and older) and CPT code 99214 (outpatient evaluation and management for an established patient, moderate complexity) can be billed together only if the provider performs and documents a significant, separately identifiable medical service beyond the routine preventive exam.

Key Billing Requirements

  • Modifier -25: You must append modifier -25 to the problem-oriented E/M code (99214) to indicate that the work done for the acute or chronic problem was distinct from the routine preventive service. Do not place the modifier on the preventive code.
  • Distinct Documentation: The medical record must contain clear, separate documentation showing the clinical rationale and medical decision-making for both the preventive exam and the separate problem (such as managing an active chronic illness or a new acute complaint).

Important Insurance Considerations

  • Payer Rules Differ: While commercial insurances and some Medicare Advantage plans may cover both codes when billed together with proper documentation, traditional Medicare does not cover routine preventive codes like 99397 (instead utilizing G-codes like G0438 or G0439 for Annual Wellness Visits). Always verify specific payer guidelines before submitting.