CPT 99397: Preventive Visit for Patients 65+ – Description, Coverage & Billing Tips

Annual wellness visits play a critical role in keeping older adults healthy, and CPT code 99397 is the billing code that makes those visits happen. Whether you are a provider looking to bill accurately or a patient trying to understand your benefits, knowing what this code covers can save time, prevent claim denials, and ensure patients get the preventive care they deserve.

This guide covers the description of CPT 99397, who qualifies, what is included in the visit, coverage details, and key billing tips to help your practice get it right.

What Is CPT Code 99397?

CPT 99397 is a preventive medicine evaluation and management (E/M) code used to bill for periodic comprehensive preventive visits for established patients aged 65 and older. It falls under the CPT 99381–99397 series, which covers age-appropriate preventive visits across different patient age groups.

The "97" in the code corresponds to the 65+ age group. The visit is focused entirely on health maintenance and disease prevention, not the treatment of acute or chronic conditions. Providers use this code when conducting a complete preventive examination, including a review of medical and family history, appropriate screenings, and patient counseling.

Who Qualifies for a CPT 99397 Visit?

To bill CPT 99397 correctly, the following criteria must be met:

• The patient must be an established patient (previously seen at your practice).
• The patient must be 65 years of age or older.
• The visit must be for preventive purposes, not for evaluation or treatment of an illness or injury.
• The service must be provided by a licensed physician or qualified healthcare professional.

If the patient is a new patient, CPT 99387 would be used instead. The key distinction is that 99397 applies only to established patients in the 65+ age category.

What Does a CPT 99397 Visit Include?

A comprehensive preventive visit billed under 99397 typically includes the following components:

• Comprehensive medical history review, including past illnesses, surgeries, medications, and family history.
• Complete physical examination appropriate for the patient's age and gender.
• Age-appropriate screenings such as blood pressure checks, vision and hearing assessments, cancer screenings, and cognitive evaluations.
• Immunization review and administration of indicated vaccines.
• Counseling and anticipatory guidance on topics such as fall prevention, nutrition, physical activity, and mental health.
• Ordering of laboratory and diagnostic tests as appropriate (e.g., cholesterol panels, blood glucose, colonoscopy referrals).

The focus is on maintaining health and catching potential issues before they become serious. Providers should document all elements thoroughly to support the claim, as incomplete documentation is one of the leading causes of 99397 claim denials.

CPT 99397 Coverage: Medicare vs. Private Insurance

Medicare Coverage

Medicare does not cover CPT 99397 as a standard benefit. Traditional Medicare Part B does not pay for routine physical exams. However, Medicare does offer the Annual Wellness Visit (AWV) under different HCPCS codes (G0438 and G0439). If you attempt to bill 99397 for a Medicare patient, the claim will likely be denied.

For Medicare patients, it is essential to use the appropriate AWV codes instead. Providers should educate front-desk staff and billers on this distinction to avoid common billing errors.

Private Insurance Coverage

Most commercial insurance plans and Medicaid-managed care plans do cover CPT 99397 as part of their preventive care benefits. Under the Affordable Care Act (ACA), many plans are required to cover preventive services with no cost-sharing for the patient. However, coverage details vary by plan, so always verify benefits before the visit.

Billing Tips to Avoid Claim Denials

Correctly billing CPT 99397 requires attention to documentation and coding rules. Here are the most important billing tips:

• Verify insurance eligibility and benefits before the visit. Confirm that the patient's plan covers preventive visits and whether any cost-sharing applies.
• Do not bill 99397 for Medicare patients. Use the appropriate Annual Wellness Visit codes (G0438 or G0439) for Medicare beneficiaries.
• Document all visit components thoroughly. The chart should reflect a comprehensive review of history, a complete exam, and counseling/guidance provided.
• Understand how to handle same-day problem visits. If a significant, separately identifiable E/M service is also provided during the same encounter, it can be billed separately with modifier -25, but must be well documented.
• Use the correct ICD-10 diagnosis code. For a routine preventive visit, the primary diagnosis is typically Z00.01 (with abnormal findings) or Z00.00 (without abnormal findings).
• Frequency limits may apply. Most payers cover one preventive visit per year. Billing a second visit within 12 months may result in denial.
• Train your billing team on payer-specific rules. Coverage policies for preventive visits differ widely between commercial payers, so staff should stay current with each payer's requirements.

CPT 99397 and Chronic Care Management

Many patients who qualify for CPT 99397 also live with one or more chronic conditions. For these patients, preventive visits are an important touchpoint, but they represent just one layer of care. Practices caring for older adults with chronic conditions often benefit from pairing annual preventive visits with structured programs like Chronic Care Management (CCM), which allows providers to deliver and bill for coordinated care between visits.

Using both CPT 99397 and appropriate chronic care codes together can significantly improve patient outcomes, reduce hospitalizations, and support practice revenue without duplicating services.

Common Mistakes to Avoid

Even experienced coders can make errors with CPT 99397. Some of the most frequent mistakes include:

• Billing 99397 for new patients instead of CPT 99387.
• Using 99397 for Medicare patients instead of the AWV HCPCS codes (G0438/G0439).
• Failing to document all required components of the visit.
• Not checking annual frequency limits before scheduling a second preventive visit.
• Using the wrong ICD-10 code or failing to append the correct diagnosis to the claim.

Summary

CPT 99397 is a foundational code for practices that serve patients aged 65 and older. When billed correctly, it ensures providers are reimbursed for the comprehensive preventive care they deliver, and it helps patients take full advantage of their insurance benefits. The key is knowing which patients and payers it applies to, documenting thoroughly, and understanding the important distinctions from Medicare's Annual Wellness Visit program.

For practices looking to streamline care delivery for older adults, integrating preventive visits into a broader care management strategy, including remote monitoring and between-visit support, can further enhance outcomes. Learn more about how Circle Care supports care teams in managing complex patient populations more effectively.

Frequently Asked Questions

Q1. What is the difference between CPT 99397 and the Medicare Annual Wellness Visit? 

CPT 99397 is a preventive E/M code used for established patients aged 65+ and is covered by most commercial insurance plans, but not by traditional Medicare. The Medicare Annual Wellness Visit is billed under HCPCS codes G0438 (first visit) or G0439 (subsequent visits) and is specifically designed for Medicare beneficiaries. Billing 99397 for a Medicare patient will typically result in a claim denial.

Q2. Can CPT 99397 be billed for a new patient? 

No. CPT 99397 is reserved for established patients aged 65 and older. If a patient is being seen for the first time at your practice, the correct code is CPT 99387, which covers the initial comprehensive preventive visit for the same age group.

Q3. How often can CPT 99397 be billed? 

Most commercial payers allow CPT 99397 to be billed once per year (every 12 months). Submitting a claim for a second preventive visit within the same 12-month period will likely be denied. Always verify the specific frequency policy with the patient's insurance plan before scheduling.

Q4. What ICD-10 code should be used with CPT 99397? 

The most commonly used diagnosis codes are:

• Z00.00 – Encounter for general adult medical examination without abnormal findings
• Z00.01 – Encounter for general adult medical examination with abnormal findings

Use Z00.01 when the visit reveals an incidental finding that requires further evaluation or follow-up.

Q5. Can CPT 99397 and a problem-focused E/M code be billed on the same day? 

Yes, in certain situations. If a significant, separately identifiable medical service is provided during the same encounter, for example, the provider also evaluates and manages an acute condition, the problem-focused E/M code can be billed alongside 99397 using modifier -25. However, both services must be thoroughly documented to support separate billing.

Q6. Does CPT 99397 cover lab tests and screenings? 

The 99397 code covers the physician's evaluation, counseling, and the ordering of appropriate tests, but laboratory work and diagnostic screenings are typically billed separately under their own CPT codes. Patients should check with their insurance plan to understand how those additional services are covered.

Q7. What happens if CPT 99397 is denied by the payer? 

If a claim is denied, the first step is to review the reason code on the Explanation of Benefits (EOB). Common reasons include incorrect patient age, wrong patient type (new vs. established), frequency limit exceeded, or the payer not covering preventive visits. Correcting the documentation or code and resubmitting or filing an appeal with supporting clinical notes can often resolve the denial.