The question of whether Medicare covers the traditional annual physical exam, represented by CPT code 99397 for established patients over age 65, is a common source of confusion. Unlike many commercial insurance plans that cover this comprehensive checkup, the federal Medicare program handles preventive services differently. Medicare Part B, which covers outpatient medical services, operates under a specific framework focused on medically necessary care and defined preventive benefits. This distinction means that the standard physical examination is generally not a covered service under Original Medicare.
The Coverage Status of the Annual Physical Exam
Medicare does not typically cover the comprehensive annual physical exam billed with CPT code 99397. This code reports a periodic, comprehensive preventive medicine evaluation for established patients 65 years or older. The reason for this exclusion is rooted in the program’s statutory mandate, as routine physical checkups are considered statutorily excluded services under Medicare Part B. While Medicare covers services deemed “medically necessary” to treat a specific illness or injury, a routine checkup performed when the patient has no symptoms falls outside this definition. This difference necessitates the use of alternative, Medicare-specific services and codes for preventive care, which focus more on health planning and risk assessment.
Medicare’s Initial Preventive Physical Examination
While the traditional physical is not covered, Medicare does offer a one-time service known as the Initial Preventive Physical Examination (IPPE), often informally called the “Welcome to Medicare” visit. This benefit is available to new Medicare beneficiaries and must be completed within the first 12 months of their enrollment in Medicare Part B. The IPPE utilizes the specific Healthcare Common Procedure Coding System (HCPCS) code G0402. Despite its name, the IPPE is not a full physical exam but rather a health promotion and disease prevention visit. Components include a review of the beneficiary’s medical and social history, risk factors for depression, and an assessment of functional ability and safety. The visit also includes measurements like height, weight, body mass index, and blood pressure, along with a visual acuity screen. Counseling and education on other Medicare-covered preventive services, such as a once-in-a-lifetime screening electrocardiogram (ECG), are also provided.
The Recurring Annual Wellness Visit
After the first 12 months of Part B enrollment, beneficiaries become eligible for the recurring Annual Wellness Visit (AWV), which is intended to be performed annually. The AWV is billed using HCPCS code G0438 for the initial visit and G0439 for all subsequent annual visits, and it must occur at least 12 months after the IPPE or previous AWV. The primary goal of the AWV is to create or update a Personalized Prevention Plan of Service (PPPS). This visit focuses heavily on non-physical assessment and planning, distinguishing it clearly from the traditional physical exam.
Required elements include:
- A health risk assessment.
- An update to the patient’s medical and family history, providers, and medications.
- Detection of cognitive impairment through direct observation or a standardized screening tool.
- A review of functional ability and a safety assessment, such as screening for fall risk.
The AWV also requires establishing a written screening schedule for the next five to ten years for appropriate Medicare-covered preventive services. While measurements like blood pressure and body mass index are taken, the AWV expressly does not include a routine, hands-on physical examination or routine laboratory work. The focus remains on proactive planning and risk factor management.
Patient Costs and Combining Diagnostic Services
The IPPE and the AWV are generally covered at 100% by Medicare Part B, meaning the beneficiary does not owe a deductible or copayment for the services themselves. This cost-free coverage encourages beneficiaries to utilize these preventive planning tools. However, the financial landscape changes immediately if the provider performs non-covered services during the same visit.
If a provider addresses a new or existing medical condition, such as evaluating a patient’s shortness of breath or performing a full, hands-on physical exam, the visit shifts from purely preventive to diagnostic. These diagnostic services are typically subject to the standard Part B deductible and 20% coinsurance. To bill for both the covered AWV and a non-covered service on the same day, providers often append a modifier to the covered AWV code to indicate that a separately identifiable, medically necessary service was also performed.
For services that Medicare never covers, like the non-preventive portions of a traditional physical, providers are encouraged to issue an Advance Beneficiary Notice of Noncoverage (ABN). The ABN is a form that informs the patient that Medicare is not expected to pay for the specific service and transfers the financial responsibility to the patient if they choose to proceed. This documentation ensures the patient understands the potential out-of-pocket costs before receiving the service.