Is 99397 billable to Medicare? Yes, but with specific conditions. Code 99397 is used for preventive services, specifically for a comprehensive preventive medicine evaluation for established patients aged 65 and older. However, Medicare typically does not cover routine preventive services, so this code may not be reimbursed unless it is part of a covered service under Medicare’s guidelines.
What is CPT Code 99397?
CPT code 99397 is a billing code used for preventive medicine services. It represents a periodic comprehensive preventive medicine reevaluation and management of an established patient, typically including an age and gender-appropriate history, examination, counseling, anticipatory guidance, and risk factor reduction interventions. This code is specifically designated for patients aged 65 years and older.
Key Features of CPT Code 99397
- Age Group: 65 years and older
- Service Type: Preventive medicine reevaluation
- Components: Includes a comprehensive examination and counseling
Is 99397 Covered by Medicare?
Medicare generally does not cover routine preventive services, including those billed under CPT code 99397. Medicare Part B may cover some preventive services, but these are typically specific screenings or immunizations rather than comprehensive exams. However, there are exceptions and scenarios where parts of the service might be covered if they align with Medicare’s preventive services guidelines.
Instances When Medicare Covers Preventive Services
- Annual Wellness Visit: Medicare covers an Annual Wellness Visit, which includes a health risk assessment and personalized prevention plan, but it is not the same as a comprehensive physical exam.
- Screenings and Vaccinations: Medicare covers specific preventive services like flu shots, mammograms, and diabetes screenings.
How to Bill Medicare for Preventive Services?
When billing Medicare, it is crucial to use the correct codes and ensure that the services provided align with Medicare’s covered preventive services. Here are some tips:
- Identify Covered Services: Check Medicare’s list of covered preventive services to determine what is billable.
- Use Appropriate Codes: Use specific Medicare billing codes for covered preventive services like G0438 for the initial Annual Wellness Visit.
- Document Thoroughly: Ensure comprehensive documentation to support the services billed.
What Are Alternatives to 99397 for Medicare Patients?
For Medicare patients, alternative codes and services may be more appropriate:
- G0438: Initial Annual Wellness Visit
- G0439: Subsequent Annual Wellness Visit
- G0402: Welcome to Medicare Preventive Visit
These codes are specifically designed for Medicare’s preventive services and are typically covered when the requirements are met.
People Also Ask
What is the difference between 99397 and G0438?
CPT code 99397 is for a comprehensive preventive exam, while G0438 is for an Initial Annual Wellness Visit covered by Medicare. The G0438 focuses on preventive planning rather than a full physical exam.
Can I bill 99397 and G0438 together?
No, these codes should not be billed together as they represent different services. G0438 is covered by Medicare, whereas 99397 is not typically reimbursed by Medicare.
How often can you bill G0438?
The G0438 code can be billed once per lifetime for each patient, as it is for the initial Annual Wellness Visit. Subsequent visits should use G0439.
Does Medicare cover preventive exams?
Medicare covers specific preventive services like screenings and vaccinations but does not cover routine comprehensive exams like those billed under 99397.
What should providers do if 99397 is not covered?
Providers should inform patients about potential out-of-pocket costs and consider billing for specific covered services separately to maximize Medicare reimbursement.
Conclusion and Next Steps
Understanding the nuances of billing Medicare for preventive services is essential for healthcare providers. While 99397 is not typically covered, using the correct Medicare codes can ensure that patients receive the preventive care they need without unexpected costs. Providers should stay informed about Medicare’s coverage policies and educate patients about their options.
For more information on Medicare billing and preventive services, consider exploring resources on Medicare’s official website or consulting with a billing specialist to optimize your practice’s reimbursement process.
