99397 CPT Code (2023) | Description, Guidelines, Reimbursement & Example

99397 CPT code specifies an individual’s comprehensive preventive medicine reevaluation, including age and gender-appropriate history, investigation, and risk guidance. Periodic complete preventative health reevaluation and management of an individual, including demographic characteristics relevant to background, physical, mentoring guideline factor reduction initiatives, ordering of testing facilities procedures, and established patient.

Summary

It is possible to report E/M (preventive evaluation and management) codes 99381-99397 for all age groups (infants, children, adolescents, and adults). The patient’s age will play a key role in determining the extent and focus of the services. In the CTP code 99397, the patient’s age is approximately above sixty-five years.

Since these procedures are part of the preventive medicine E/M service, it is not suitable to report them separately for the pelvic exam, including the  Scan or the breast exam. A different way of documenting these services can be requested by third-party payers, even though it conforms with CPT criteria.

Request information from third-party payers on reporting requirements. Even though the CPT Assistant page referenced predates the Affordable Care Act, the advice to contact your payers about their reporting needs is still essential.

Preventative services may include a new or modified problem requiring additional effort to complete the main components of an actual concern examination and monitoring (E/M) service.

In that case, you should bill for both services with modifier 25 added to the latter. According to the CMS guide to wellness visits, an E/M service that is significant, individually identifiable, and medically necessary may add to a wellness visit along with the E/M service with modifier 25. 

Such actions could include ordering or reviewing diagnostic testing, renewing medication or referrals, and making other treatment adjustments.

 According to CPT and CMS, altering the patient’s therapy to bill for a second service is unnecessary. While performing two services is perfectly acceptable, the only statement for one is against CPT guidelines and isn’t suitable for practice revenue.

Code Description

A healthcare provider visits a 65-plus-year-old patient for a regular well-patient visit. Patients without a primary complaint receive E/M treatments during “well visits,” another name for preventive medicine.

The official description of CPT code 99397 is: “Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older.”

Instead of treating a disease or injury, the visit aims to check the patient’s overall health and identify future health issues before they become more serious. (or the signs or symptoms of an illness or injury).

CPT® uses the “three-year rule” to decide whether a product is new or established. At either 99381-99387 or 99381-99387, the code may base on the patient’s age (which may state in the code descriptor) (99391-99397). Physicians can find a “Decision Tree for New and Existing Patients” in the Diagnostic and Treatment Services Guidelines section of the CPT® codebook.

For a young child, measurements of physical growth and developmental milestones like talking, crawling, and sleeping patterns will take. Examples of anticipated requirements include using child safety seats and other safety concerns and the introduction of new cuisines.

Adolescent preventive treatments include scoliosis screening, growth and development evaluations, and vaccine reviews. Health and self-care, drug, alcohol, tobacco use, and sexual activity are preemptive advice.

An entire preventative appointment for the 65-year-old female patient includes a gynecological checkup and breast exam. Older male gender patients (approximately 65 years old) may need to examine their whole genital system, including the scrotum and testes. Preemptive advice will cover appropriate drinking and smoking, sex practices, nutrition, and physical activity.

Billing Guidelines

99381 – 99397 CTP code may not include CPT codes (preventative medicine services) in Medicare’s coverage. A disclaimer of liability isn’t required when billing a Medicare patient for a preventive medicine consultation. It means that the patient has all responsibility for accruing debt. Insurance companies that don’t include these services in the person’s policy will charge a different rate.

Age-specific CPT codes 99381 – 99397 CTP code for thorough preventative examinations are available for new and established office patients, starting at infancy. Preventive medicine services in the CPT codebook may code using evaluation and management (E/M) categories. NPS, APPs, and PAs can use these E/M codes as long as they’re certified by a physician.

CPT defines chronic, stable conditions as those that are not “severe enough to demand more work” by a complete medical history and physical examination. Discussion of age-appropriate counseling, screening labs, and testing for minor disorders that don’t demand additional effort

According to CPT, a preventive visit’s history should not focus on a patient’s primary complaint or current illness. Instead, it demands a “complete system evaluation and comprehensive or interval historical, familial, and social history and a thorough assessment/history of relevant risk factors. The clinician may give immunizations during the prevention treatment and acquire and schedule laboratory/diagnostic tests.

 For example, in a comprehensive preventive exam, the components are determined by the patient’s age and risk factors rather than the patient’s current medical condition. An ICD 10 CM code for screening will assign to all labs and other tests ordered during a prophylactic visit. 

If a patient wants a medical condition addressed simultaneously as their yearly physical exam, the doctor can bill for an evaluation and management service. Patients with well-controlled chronic diseases and no complaints may avoid they are “establishing care” and will not by the physician. Prophylactic visits to Medicare and commercial insurance providers will consider.

As with many other medical services, you can get a bundle deal on preventive visits. Regarding E/M office visits (99201–99215), the coding requirements for problem-oriented visits (99201–99215) are more complex, making it easier to document preventive appointments. Elements that must be present include:

A bill for a service may include an ICD 10 code that explains what the service may use. It may be best to utilize “Z codes” because there is no patient complaint during a good visit (Factors influencing health status and contact with health services). The following is an example of a scenario:

• Newborns younger than eight days old are subject to Z00.110, a health evaluation.
• Z00.111 Newborn health checkups from 8 to 28 days of age
• Routine child health examinations may yield abnormal results, according to Z00.121.
• Z00.129 handles child health examinations that give no abnormal results.
• Z00.00 Visit for a standard adult medical examination that does not detect any abnormalities
• The medical evaluation of an adult with aberrant findings is Z00.01.
• contact with abnormal results after routine gynecological examination Z01.411
• There were no abnormalities found during the usual gynecological checkup Z01.419

Reimbursement

No matter how you call it, 99397 CTP code and 99387 indicate preventive care examinations that are never reimbursed by Medicare, no matter how you label it.

There is no way to combine the AWV or Welcome to Medicare Visit with the Annual Preventive Exam (CPT code 99397). As a standalone product, it can make the sale: All 99381-99387, 99409-99397, 99409-99398, and 940909-99398, not even one iota A once-in-a-lifetime chance.

Insurance coverage for preventive visits varies, so knowing what the patient’s health plan covers is critical. Preventive checkups are usually limited to once a year, and most insurers cover not all tests.

The instruction may separate invoices for vaccinations, vaccination administration, fecal occult blood testing, audiometry, and pap smear collection. The cost of a visual acuity test may not include in the fee.

Billing Example

An internal medicine doctor (preventative medicine) examines an established Medicare patient annually. When the appointment may schedule, the patient(approximately 65 years old)  stated that he only wanted to be seen for an annual physical and had no issues. But it is during the session that the doctor discovers that the patient has an enlarged prostate. 

Due to this finding, a more thorough history and physical examination may require. Office visit codes 99212-99215 may report with the 25 modifiers if an internist finds a “major” issue during an annual physical and warrants extra testing, prescription, or problem resolution.

Preventative established patients over 65 should be reported as CPT code 99397, whereas 99212-99215-25 will record as 99212-99215-25. (assessment and discussion of enlarged prostate).s