CPT codes are a standardized language used by healthcare providers to describe medical, surgical, and diagnostic services to health insurance payers. CPT 99397 is the specific code used to report a periodic comprehensive preventive medicine reevaluation for an established patient who is 65 years of age or older. This code signifies a “well visit” or “annual physical” focused entirely on maintaining health and preventing disease, rather than treating an existing illness. It applies only to patients who have been seen by the practice previously, distinguishing it from initial preventive exams.
The Specific Preventive Services Covered
The comprehensive preventive medicine reevaluation represented by CPT 99397 is a thorough, proactive health check designed specifically for the older adult population. A core component of this visit is a detailed update of the patient’s medical and social history, including a review of current medications, family history, and lifestyle factors. This history allows the physician to identify subtle changes in health status since the last visit.
The code also mandates an age-appropriate physical examination, which is a hands-on assessment of the patient’s physical well-being. This exam is tailored to preventive care, focusing on systems relevant to aging, such as cardiovascular, musculoskeletal, and neurological function. The examination often includes checking vital signs, assessing balance, and performing visual and auditory screenings.
A significant portion of the visit involves counseling and anticipatory guidance focused on risk factor reduction. The physician provides guidance on health maintenance topics like optimizing diet, establishing safe exercise routines, and strategies for fall prevention. Furthermore, the visit ensures the patient is up-to-date on all recommended immunizations, such as the influenza, pneumococcal, and shingles vaccines.
The visit also includes ordering necessary age-appropriate screening tests and laboratory procedures. This may involve writing orders for mammograms, colonoscopies, bone density scans, or blood work to screen for conditions like diabetes and high cholesterol. The ordering of these tests or the administration of a vaccine is billed separately from the main 99397 visit code, as they are distinct services performed in addition to the evaluation and management.
Differences from Other Medicare Visits
The concept of an “annual visit” for a senior can be confusing because CPT 99397 is often contrasted with the Medicare Annual Wellness Visit (AWV), billed under codes G0438 or G0439. The most important distinction is that Medicare Part B generally does not cover 99397, considering it a routine physical exam. Instead, Medicare pays for the AWV, which focuses on health risk assessment and creating a personalized prevention plan, often without a hands-on physical exam.
The Annual Wellness Visit is primarily a planning and counseling session that includes a questionnaire to identify risk factors, a review of medical providers and medications, and an assessment of cognitive function. Unlike 99397, the AWV does not require a comprehensive physical examination. Patients may opt to have both a Medicare AWV and a CPT 99397-style physical exam, but they must understand the latter is a non-covered service under traditional Medicare.
The CPT 99397 visit must also be distinguished from a problem-focused, or “sick,” visit, billed using standard Evaluation and Management (E/M) codes (e.g., 99213, 99214). The preventive reevaluation is strictly for asymptomatic patients and is intended to assess overall health. If a patient presents with a new complaint, such as a severe headache or an acute infection, or requires significant management of a chronic condition, that service must be documented and billed separately.
If a patient receives the preventive exam (99397) and also has a significant, separately identifiable problem addressed during the same encounter, the provider will bill for both services. The problem-focused E/M code will have a special modifier added to indicate that two distinct services were performed. This separation ensures the insurance payer understands which portion of the visit was preventive and which was for treating an illness.
Understanding Coverage and Patient Costs
The comprehensive preventive exam described by CPT 99397 is typically limited to once every 12 months by most insurance carriers. This frequency restriction is standard for most preventive services to ensure patients receive a regular check on their health status. Adhering to this timeframe is important, as billing too early will often result in a claim denial.
Insurance coverage for 99397 varies significantly depending on the patient’s plan. While most commercial insurance plans and many Medicare Advantage plans cover this code as part of their annual physical benefit, traditional Medicare Part B does not cover it. For traditional Medicare, the code is considered a non-covered service, meaning the patient is responsible for the full cost of the visit.
Patient financial responsibility becomes an issue when a non-covered CPT 99397 is performed. For patients with traditional Medicare, the physician is encouraged to issue an Advance Beneficiary Notice of Non-coverage (ABN) before the visit, informing the patient they will be responsible for the charge. Costs can also arise if a patient discusses a new medical problem or receives non-covered screening tests during the preventive visit.
Even when CPT 99397 is covered by a commercial plan, potential costs can still exist. While many preventive services mandated by the Affordable Care Act are covered without cost-sharing, a comprehensive physical may or may not fall under that zero-cost provision. Patients should verify with their insurance carrier whether a deductible or copayment will apply before scheduling the exam.