Can I bill 99397 to Medicare? The short answer is no. Medicare does not cover the CPT code 99397, which is used for a comprehensive preventive medicine evaluation and management service. Instead, Medicare provides coverage for a range of other preventive services under its Annual Wellness Visit.
What is CPT Code 99397?
CPT code 99397 is used by healthcare providers to bill for a comprehensive preventive medicine evaluation for established patients aged 65 years and older. This service includes a thorough examination, health risk assessment, and counseling to prevent future health issues. It is typically part of a routine check-up that focuses on preventive care rather than diagnosing or managing specific illnesses.
Why Doesn’t Medicare Cover CPT Code 99397?
Medicare does not cover CPT code 99397 because it classifies it as a routine preventive service, which is generally not covered under traditional Medicare plans. Instead, Medicare has its own set of preventive services, including the Annual Wellness Visit, which serves a similar purpose but has specific requirements and components.
What Does Medicare Cover Instead?
Medicare offers a variety of preventive services to help maintain the health of its beneficiaries. These services include:
- Annual Wellness Visit: This visit is designed to develop or update a personalized prevention plan based on your current health and risk factors. It is covered once every 12 months.
- Welcome to Medicare Preventive Visit: Available within the first 12 months of enrolling in Part B, this visit includes a review of medical and social history related to your health.
- Screening Services: Medicare covers screenings for various conditions, such as cardiovascular disease, diabetes, and cancer.
How to Bill Medicare for Preventive Services?
When billing Medicare for preventive services, it is crucial to use the correct codes to ensure coverage. Here are some steps to follow:
- Determine Eligibility: Confirm that the patient is eligible for the specific preventive service under Medicare.
- Use Correct Codes: Use codes such as G0438 for the first Annual Wellness Visit and G0439 for subsequent visits.
- Document Thoroughly: Ensure that all documentation is complete and accurately reflects the services provided.
Example: Annual Wellness Visit vs. Comprehensive Preventive Visit
| Feature | Annual Wellness Visit (Medicare) | Comprehensive Preventive Visit (CPT 99397) |
|---|---|---|
| Coverage | Yes | No |
| Frequency | Annually | Varies |
| Components | Health risk assessment, plan | Full physical exam, counseling |
| Cost to Patient | Typically no cost | Out-of-pocket |
People Also Ask
What is included in an Annual Wellness Visit?
An Annual Wellness Visit includes a health risk assessment, personalized prevention plan, and routine measurements such as weight and blood pressure. It does not include a full physical exam.
How often can you have a Medicare Wellness Visit?
Medicare covers an Annual Wellness Visit once every 12 months. It is important to schedule these visits accordingly to ensure coverage.
Are there any costs for a Medicare Wellness Visit?
There is typically no cost for the Medicare Wellness Visit if the provider accepts assignment. However, if additional tests or services are performed, there may be costs associated.
What is the difference between a physical exam and a wellness visit?
A physical exam is a comprehensive evaluation of the body to check for signs of disease, while a wellness visit focuses on preventive health measures and creating a personalized health plan.
Can Medicare Advantage plans cover 99397?
Some Medicare Advantage plans may offer additional benefits, including coverage for services like those billed under CPT 99397. It is important to check with the specific plan provider for details.
Conclusion
While you cannot bill 99397 to Medicare, understanding the preventive services that Medicare does cover can help you make the most of your benefits. Consider scheduling an Annual Wellness Visit to maintain your health and address any potential risks. For more detailed guidance, consult with your healthcare provider or Medicare representative.
For further reading, explore topics like "Medicare Part B Preventive Services" and "Understanding Medicare Coverage Options" to maximize your healthcare benefits.
