Medicare does not cover the 99397 CPT code, as this code is used for a comprehensive preventive medicine evaluation and management service, which Medicare typically does not include in its coverage. Understanding what Medicare covers can help beneficiaries plan for potential out-of-pocket expenses.
What is CPT Code 99397?
The 99397 CPT code is a billing code used by healthcare providers to document a comprehensive preventive medicine evaluation and management service for established patients aged 65 and older. This service includes a thorough physical examination and counseling on preventive health measures. However, because it is categorized as a preventive service, it is not covered by Medicare Part B, which focuses on medically necessary services.
Why Doesn’t Medicare Cover 99397?
Medicare Part B generally covers services that are considered medically necessary, such as doctor visits, outpatient care, and certain preventive services. However, routine physical exams like those billed under the 99397 code are not considered necessary under Medicare’s guidelines. Instead, Medicare offers a "Welcome to Medicare" preventive visit and an annual Wellness Visit, which are different from a full physical exam.
Alternatives to 99397 Under Medicare
While Medicare does not cover the 99397 code, there are other options for preventive care under Medicare:
- Welcome to Medicare Visit: Available once within the first 12 months of enrolling in Part B. It includes a review of medical history, risk factors, and preventive services education.
- Annual Wellness Visit: Available once every 12 months after the initial 12-month period. It focuses on creating or updating a personalized prevention plan based on current health and risk factors.
These visits do not include the comprehensive physical exam covered by 99397 but offer valuable preventive services.
How to Plan for Out-of-Pocket Costs
If you need a comprehensive physical exam, consider the following options:
- Check with Your Medicare Advantage Plan: Some Medicare Advantage Plans may cover services not included in Original Medicare, such as routine physical exams.
- Supplemental Insurance: Consider purchasing supplemental insurance that might cover additional services.
- Budgeting for Healthcare Costs: Plan for potential out-of-pocket expenses by setting aside funds for services not covered by Medicare.
People Also Ask
What is included in a 99397 exam?
A 99397 exam includes a comprehensive review of medical history, a full physical examination, and counseling on preventive health measures. It may also involve screenings and immunizations based on age and risk factors.
How often can you have a 99397 exam?
The 99397 exam is typically offered annually for established patients aged 65 and older. However, frequency can vary based on individual health needs and provider recommendations.
What preventive services does Medicare cover?
Medicare covers a range of preventive services, including screenings for cardiovascular disease, cancer screenings, flu shots, and the Welcome to Medicare and Annual Wellness Visits. These services help detect health issues early.
Can Medicare Advantage Plans cover 99397?
Some Medicare Advantage Plans might offer coverage for services like the 99397 exam. It’s essential to check with your plan provider to understand what is included.
How do I schedule a Medicare-covered preventive visit?
To schedule a Medicare-covered preventive visit, contact your healthcare provider and specify that you want to book a Welcome to Medicare Visit or an Annual Wellness Visit. These visits are designed to focus on preventive care and wellness.
Conclusion
While Medicare does not cover the 99397 CPT code, beneficiaries can still access preventive care through the Welcome to Medicare Visit and Annual Wellness Visit. To maximize your healthcare benefits, explore options like Medicare Advantage Plans or supplemental insurance. For more detailed information on Medicare coverage, consider visiting the official Medicare website or consulting with a Medicare expert.
