CPT® Code 99397

Quick Reference: CPT 99397

• Definition: Periodic comprehensive preventive medicine reevaluation for an established patient age 65 years and older.
• Components: “Head-to-Toe” physical exam, age-appropriate screenings (Fall risk, Polypharmacy), and anticipatory guidance.
• Medicare Rule: Statutorily Excluded (Status N). Use G0438/G0439 for Annual Wellness Visits instead.
• Reimbursement: Approx. $130–$180 (Commercial). Patient pays 100% if billed to Original Medicare (ABN advised).
• Documentation: Must capture specific senior-health elements (cognitive status, ADLs, sensory deficits) to justify “comprehensive” nature.

CPT® 99397 represents the annual “routine physical” for established patients aged 65 and older. While straightforward in commercial billing, it creates significant confusion for Medicare beneficiaries because it is a non-covered service under Original Medicare, which instead covers the “Annual Wellness Visit” (AWV).

Clinical Deep Dive: What is a “Comprehensive” Senior Exam?

For CPT 99397, “comprehensive” is defined by the patient’s age and risk factors, not just counting organ systems. A robust 65+ preventive exam must address geriatric syndromes as outlined by the AMA:

• Polypharmacy Review: Detailed reconciliation of prescription and OTC meds to reduce adverse drug events.
• Functional Assessment (ADLs/IADLs): Can the patient bathe, dress, manage finances, and drive safely?
• Fall Risk: Tests like the “Timed Up and Go” (TUG) or 30-second chair stand.
• Sensory Deficits: Objective screening for hearing (whisper test/audiometry) and vision (Snellen chart).
• Cognitive Screen: Mini-Cog or similar tool to establish a baseline for dementia.
• Physical Exam: Unlike the Medicare AWV (which requires no touch), 99397 requires a hands-on exam (Heart, Lungs, Abdomen, Neuro, Skin, Musculoskeletal).

The “Medicare Triangle”: 99397 vs. AWV vs. IPPE

Understanding the difference between these three codes is critical for avoiding denials and patient billing disputes.

Practice Management Tip: Medicare Advantage plans often cover 99397 as an extra benefit. Verify the back of the patient’s card. If they have a PPO/HMO Advantage plan, you may be able to bill 99397 successfully. For Original Medicare, you must bill the patient.

Payer-Specific Guidelines

flowchart TD
    A[Patient Age 65+ Requests Annual Physical] --> B{What is the payer?}
    B -->|Original Medicare| C[99397 is Statutorily Excluded]
    C --> D[Issue ABN to Patient]
    D --> E[Bill 99397-GY]
    E --> F[Patient Pays 100%]
    B -->|Medicare Advantage| G{Plan covers routine physical?}
    G -->|Yes| H[Bill 99397 per plan rules]
    G -->|No| C
    B -->|Commercial| I[Covered at 100% under ACA]
    I --> J[Bill 99397 with Z00.00/Z00.01]
    A --> K{Acute problem also addressed?}
    K -->|Yes| L[Add 9921x-25 with separate documentation]
    K -->|No| M[Bill 99397 alone]

Original Medicare (Part B)

Medicare has a statutory exclusion for “routine physical checkups”.

Action: If a patient demands a physical exam (99397), issue a voluntary ABN (Advance Beneficiary Notice). Bill 99397 with modifier -GY (Item statutorily excluded). This generates a denial (“Patient Responsibility”), allowing you to collect the fee from the patient or their secondary insurance.

Medicare Advantage (Part C)

Many plans (UHC, Humana, Aetna Medicare) blend the rules.

Common Scenario: The plan covers 1 routine physical (99397) per year at $0 cost share.

Bundling Warning: These plans often bundle the Pap/Pelvic (G0101/Q0091) into the 99397 payment. Do not unbundle unless the contract explicitly allows it.

Commercial & Medicaid

Commercial: Covered at 100% under ACA mandates. Watch for “calendar year” vs. “365 day” frequency limits.

Medicaid: Varies by state. NC Medicaid, for example, covers one adult preventive exam per year for ages 21+. Document developmental screenings and anticipatory guidance clearly.

Advanced Modifier Usage

Modifier 25 (The “Sick” Visit Add-On)

Used when a significant, separately identifiable problem is managed during the physical.

Example: A 68-year-old comes for a physical (99397) but reports new onset dizziness. You perform a Dix-Hallpike maneuver and order an MRI.

Coding: 99397 + 99214-25.

Documentation: You must have a separate HPI, Exam, and Plan section for the dizziness. The “Physical” exam findings (skin, heart, etc.) do not count toward the “Sick” visit MDM.

Modifier 33 (Preventive Service)

Generally not needed on 99397 (it is inherently preventive). However, use Modifier 33 on ancillary services (like labs or X-rays) if they are being done for screening purposes to signal the payer to waive the copay.

Advanced ICD-10 & SDOH Coding

Primary Z-Codes

• Z00.00: General exam, no abnormal findings. (Use if chronic conditions are stable).
• Z00.01: General exam, with abnormal findings (e.g., a new lump, uncontrolled HTN).

Social Determinants of Health (SDOH)

For 2026, capturing SDOH is crucial for risk adjustment. If you discuss housing, food, or safety, code it:

Z59.0: Homelessness.

Z59.4: Lack of adequate food.

Z60.2: Problems related to living alone (common in 65+).

These codes can support the medical necessity of extra counseling time or referrals.

Bundling & Ancillary Services

What to Bill Separately

• Immunizations: 90471/90472 + Vaccine Product (Note: Use G-codes for Medicare Flu/Pneumo).
• Labs: Venipuncture (36415) and Labs (80061, 80053).
• Pelvic Exam Add-on (+99459): New practice expense code for pelvic exams. Medicare bundles this, but some commercial payers reimburse it. List it separately if performed.

What is Bundled (Do Not Bill)

• Vision Screening (Snellen): Generally included in the comprehensive exam.
• Counseling Risk Factors: Basic diet/exercise counseling is part of 99397. Do not bill 99401 unless it is a distinct, timed session regarding a specific problem (e.g., obesity).

Audit-Proof Documentation Strategy

The “Hybrid” Note Structure:

To safely bill both a Physical (99397) and a Sick Visit (99213-25), structure your note with two distinct headers:

SECTION 1: ANNUAL PREVENTIVE EXAM

Interval History: Diet, Exercise, Vaccine Review.

Exam: Full multi-system exam.

Plan: Refill maintenance meds, order screening colonoscopy.

SECTION 2: ACUTE COMPLAINT (Right Knee Pain)

HPI: Onset 2 weeks ago, 5/10 pain.

Exam (Focused): R Knee swelling, McMurray test positive.

Plan: XR ordered, Ortho referral.

This visual separation is your best defense against “double-dipping” audits. Also ensure to track RVUs internally, as Medicare assigns 0 payment but acknowledges the work value.