The 99397 CPT code is a widely used medical billing code for preventive services provided to elderly patients. Specifically, it represents a comprehensive preventive medicine evaluation and management (E/M) service for established patients aged 65 years and older.
In today’s healthcare landscape, understanding how to correctly use CPT code 99397 is essential. Accurate billing directly impacts reimbursement rates, claim approvals, and compliance with payer guidelines.
Therefore, this guide explains everything you need to know, from definition and billing rules to reimbursement and insurance coverage, so you can avoid costly errors and maximize revenue.
What Is 99397 CPT Code? (Definition & Meaning)
99397 CPT Code Definition
CPT code 99397 refers to a preventive medicine E/M service for:
- Established patients
- Age 65 years and older
- Periodic comprehensive preventive evaluation
In simple terms, if you’re asking “what is CPT code 99397?” it is the code used for annual preventive exams for elderly patients.
99397 CPT Code Description
The 99397 CPT code description includes a complete preventive service that focuses on overall health rather than treating a specific illness. It typically involves:
- Comprehensive medical history
- Full physical examination
- Risk factor assessment
- Preventive counseling and guidance
What Is Included in CPT Code 99397?
Many providers ask, “what does CPT code 99397 mean in practice?”
It includes:
- Age-appropriate screenings
- Preventive health advice
- Immunization recommendations
- Lifestyle counseling (diet, exercise, etc.)
Importantly, no chief complaint is required, which differentiates it from problem-based visits.
99397 CPT Code Age Limit & Eligibility Criteria
The 99397 CPT code age limit is straightforward:
- Patients must be 65 years or older
- The patient must be established (not new)
Additionally, frequency plays a key role. Typically, providers use this code once per year for preventive visits.
However, do not use 99397 when:
- The visit is problem-focused
- The patient is new
- The service does not meet preventive care criteria
Understanding these rules ensures compliance and prevents claim denials.
99397 CPT Code Reimbursement Rates (2026 Guide)
Average Reimbursement Rates
The 99397 CPT code reimbursement varies depending on the payer. On average:
- Private insurance: Moderate to high reimbursement
- Commercial plans: Vary based on contracts
- Geographic regions: Payment differs by location
Factors Affecting Reimbursement
Several factors influence how much you get paid:
- Documentation quality
- Insurance contracts
- Facility vs non-facility settings
- Coding accuracy
Even small documentation errors can significantly reduce reimbursement.
Physician Fee Schedule Insights
Reimbursement also depends on the physician fee schedule. Payers determine:
- Allowed amounts
- Coverage eligibility
- Payment structure
Therefore, accurate coding and proper claim submission directly improve revenue outcomes.
Does Medicare Cover CPT Code 99397?
Medicare Coverage Rules
A common question is: “Does Medicare cover CPT code 99397?”
The answer is: No, Medicare typically does NOT cover 99397.
Instead, Medicare categorizes preventive services differently under its own system.
Medicare Replacement Codes
Medicare uses alternative codes for wellness visits:
- G0438 – Initial Annual Wellness Visit
- G0439 – Subsequent Annual Wellness Visit
These are often referred to as replacement codes for CPT 99397.
When 99397 May Be Used with Medicare
In rare cases, providers may bill 99397 with:
- Modifier -GY (non-covered service)
However, this usually results in out-of-pocket costs for patients.
Insurance Coverage for 99397 CPT Code
Private Insurance Coverage
Most private insurers cover 99397 under preventive care benefits, especially if plans comply with ACA guidelines.
In many cases:
- No copay applies
- Services are fully covered
Medicare Advantage Plans
Unlike traditional Medicare, Medicare Advantage plans may:
- Cover 99397
- Follow customized rules
Therefore, always verify plan-specific policies.
Patient Out-of-Pocket Costs
Patients may incur costs when:
- Services exceed preventive scope
- Additional E/M services are provided
- Coverage limitations apply
Thus, verifying benefits before the visit is crucial.
Billing Guidelines for CPT Code 99397
Key Billing Requirements
To bill correctly:
- Confirm the patient is established
- Ensure the visit is preventive
- Include complete documentation
Proper Claim Submission
Accurate billing requires:
- Correct ICD diagnosis codes
- Proper linkage to preventive services
- Clear separation from problem-based visits
Time & Frequency Rules
Although not strictly time-based, the typical visit lasts around 40 minutes.
Additionally:
- Frequency is usually annual
- Overuse may trigger audits
Documentation Requirements for 99397 CPT Code
Strong documentation ensures compliance and reimbursement. Required elements include:
- Comprehensive history and exam
- Risk factor analysis
- Preventive counseling notes
- Screening recommendations
Using proper clinical documentation also supports:
- Audit compliance
- Medical necessity
- Accurate coding
Remember, poor documentation leads to claim denials.
Modifier Usage with 99397 CPT Code
Modifier -25 Explained
Use modifier -25 when:
- A significant, separately identifiable E/M service is provided
- A problem-based visit occurs alongside preventive care
Modifier -GY (Medicare Non-Covered)
Use modifier -GY when:
- Billing non-covered services to Medicare
- Informing patients of financial responsibility
Common Modifier Mistakes
Avoid these errors:
- Missing modifier -25 when required
- Incorrect bundling
- Lack of supporting documentation
Proper modifier use improves claim approval rates.
CPT Code 99397 vs Other Preventive Codes
99397 vs 99396
- 99397 → Age 65+
- 99396 → Age 40–64
99397 vs G0439
- 99397 → Preventive physical exam
- G0439 → Medicare wellness visit
Preventive CPT Code Range (99381–99397)
This code belongs to the broader preventive range:
- 99381–99387 → New patients
- 99391–99397 → Established patients
Understanding this range helps build coding accuracy and consistency.
Common Billing Errors & Claim Denials
Avoid these frequent mistakes:
- Billing 99397 for Medicare patients incorrectly
- Missing documentation
- Incorrect diagnosis codes
- Failure to use modifier -25
These errors often lead to claim denials and revenue loss.
Real-World Example of 99397 CPT Code Billing
Consider this scenario:
A 70-year-old established patient visits for an annual preventive exam.
Visit Includes:
- Full medical history
- Physical examination
- Preventive counseling
Billing Outcome:
- Use 99397 CPT code
- If additional issue evaluated → add modifier -25
This example highlights proper coding and billing practices.
Tips to Maximize Reimbursement & Avoid Denials
To optimize revenue:
- Verify insurance before visits
- Follow payer-specific guidelines
- Maintain accurate documentation
- Stay updated with coding changes
Additionally, strong revenue cycle management (RCM) improves financial outcomes.
Conclusion
The 99397 CPT code plays a vital role in preventive healthcare for elderly patients. However, correct usage requires a clear understanding of billing rules, reimbursement policies, and insurance coverage.
By following proper documentation, using appropriate modifiers, and verifying insurance eligibility, providers can maximize reimbursement and reduce claim denials.
Need help with accurate medical billing and coding? Partner with Right On Time Billing Services experts to streamline your revenue cycle and ensure compliance.