Current Procedural Terminology (CPT) codes are the standardized language used by healthcare providers to describe medical, surgical, and diagnostic services for reimbursement. Understanding these codes helps patients know what their annual check-up covers. CPT 99397 is the specific numeric identifier for a comprehensive preventive medicine reevaluation and management service. This service is provided to an established patient who is 65 years of age or older, focusing entirely on maintaining health and preventing future illness.
The Specific Scope of CPT 99397
The medical system uses CPT 99397 exclusively for a periodic preventive visit, meaning the service is designed for a patient who is currently asymptomatic and not presenting with a new illness. The code is part of a larger family of CPT Preventive Medicine Services, organized by patient age and whether they are a new or established patient. The key criterion for the use of 99397 is that the patient must be 65 years of age or older.
This code is designated for an established patient, defined as an individual who has received professional services from the same physician or another physician of the same specialty in the same group practice within the past three years. This distinction ensures the provider has existing medical records to review. The service is typically performed once every 12 months, reflecting its nature as an annual check-up intended to proactively manage health over time. The focus of the visit is on health maintenance and risk reduction.
Key Components of the Periodic Preventive Exam
The periodic preventive exam defined by CPT 99397 is comprehensive and proactive. The service begins with a thorough update of the patient’s medical history, including family and social history, to identify any new or evolving risk factors since the last visit. This comprehensive history review covers all body systems, going beyond a simple problem-focused inquiry.
The examination component is an age-appropriate comprehensive physical assessment. This may include checking vital signs, visual acuity, and detailed cardiovascular, musculoskeletal, and neurological checks. This full physical assessment is a hands-on evaluation of the patient’s current physical condition, designed to detect early signs of disease or physical changes.
A significant portion of the visit involves health risk factor assessment and counseling, tailored specifically for patients 65 and older. This counseling, known as anticipatory guidance, focuses on risk reduction interventions, such as discussing lifestyle modifications, exercise, and fall prevention strategies. The visit also includes a review of age-appropriate screening recommendations and the ordering of any necessary laboratory or diagnostic procedures.
Distinguishing 99397 from Other Visits
CPT 99397 is distinct from problem-focused visits, which are often called “sick visits.” A problem-focused visit uses Evaluation and Management (E/M) codes (typically 99202–99215) when a patient presents with a specific illness or injury, such as a cough or a sprained ankle. The 99397 code is only for a preventive check. If a significant, separately identifiable new problem is addressed during the annual exam, the provider must bill for that problem-focused service separately using a modifier.
A more nuanced distinction exists between CPT 99397 and the Medicare Annual Wellness Visit (AWV), reported using HCPCS codes G0438 or G0439. The AWV is covered by traditional Medicare, but it is primarily a health risk assessment, a review of medical history, and the development of a personalized prevention plan. Notably, the Medicare AWV typically does not include a head-to-toe physical examination, which is a required component of the CPT 99397 service.
Traditional Medicare generally does not provide coverage for the CPT 99397 code, as it prefers its own AWV structure. This difference means that if a Medicare patient specifically requests a comprehensive physical exam, billed as 99397, they may be financially responsible for the cost. Coverage for CPT 99397 varies significantly among different commercial insurance plans and Medicare Advantage plans, which often cover the comprehensive physical exam component that traditional Medicare excludes.