CPT 99397 Guide (2026) Complete Preventive Medicine Billing, Documentation & Reimbursement Rules

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KEY TAKEAWAYS AT A GLANCE

✓         CPT 99397 = periodic preventive medicine visit for ESTABLISHED patients aged 65+

✓         Original Medicare does NOT cover CPT 99397 — use G0439 for subsequent Medicare AWVs instead

✓         Most commercial plans cover 99397 once annually, often at 100% with no cost-sharing

✓         Documentation must include comprehensive history, exam, screening, counseling, and preventive orders

✓         Modifier 25 required when a separate E/M problem is also addressed at the same visit

✓         Age mismatch (e.g., billing 99396 for a 65+ patient) is an automatic, non-appealable denial

✓         Practices that correctly capture preventive billing recover 12–18% more revenue annually

The Preventive Billing Problem Hiding in Plain Sight

Here is a scenario that plays out in geriatrics and primary care offices every single week: a long-time patient comes in for her annual wellness check. She is 71, has been seeing the same physician for four years, and the visit covers everything blood pressure review, fall risk screening, medication reconciliation, depression screening, immunization updates, and a counseling conversation about diet and activity. The provider spends 45 minutes being thorough and preventive. Then the claim goes out coded 99214 because that is what the billing software defaults to, or worse, 99387 the new patient code because someone confused the two.

The result is either leaving legitimate preventive revenue uncaptured, or generating a denial that takes staff time to chase, appeal, and often never fully recover. CPT 99397 is the correct code for this scenario a periodic comprehensive preventive medicine visit for an established patient aged 65 and older. It is the annual physical equivalent for seniors with commercial insurance, and it is one of the most consistently underbilled or misbilled codes in geriatrics practices across the country.

In 2026, the stakes for getting this right have grown. With CMS continuing to refine physician fee schedule guidance, commercial payers tightening documentation review, and geriatric practices serving a higher-acuity patient population than ever, billing CPT 99397 correctly is not a nice-to-have. It is a revenue protection issue.

65+ Patient age requirement established only

$120–$250 Typical commercial reimbursement range

1x/year Maximum frequency for most payers

0% Medicare (Original) coverage — use G0439

What Is CPT 99397? A Clear, Practical Definition

CPT 99397 is the AMA-designated code for a periodic comprehensive preventive medicine reevaluation and management service that is, a repeat preventive wellness visit — for an established patient who is 65 years of age or older at the time of service. The word "periodic" matters here. This is not the first time you have seen this patient. They are established, they have an existing relationship with your practice, and this visit is their routine annual preventive exam.

The service covered by CPT 99397 includes:

•         An age-appropriate and gender-appropriate history — updated from the prior visit, covering medical, family, and social history relevant to the patient's current age and risk profile

•         A comprehensive physical examination calibrated to preventive goals, not problem investigation

•         Counseling and anticipatory guidance — evidence-based health education on diet, exercise, tobacco cessation, fall prevention, medication safety, and other age-specific concerns

•         Risk factor reduction interventions tailored to the patient's identified risks

•         Ordering of appropriate laboratory or diagnostic procedures age-based cancer screenings, lipid panels, diabetes monitoring, bone density studies, etc.

This is not an E/M visit for managing a specific complaint or condition. CPT 99397 is a prevention-first service. The patient is not coming because something is wrong they are coming to ensure things stay right.

The Preventive Code Family: Where 99397 Fits

MEDICARE INSIGHT

Original Medicare does not cover CPT 99397. This is not a coverage dispute — it is a statutory exclusion written into the Social Security Act. Medicare excludes routine preventive physical examinations from Part B coverage. For Original Medicare beneficiaries, the annual wellness visit is billed using G0439 (Subsequent Annual Wellness Visit after the first G0438). These are entirely different services with different components and documentation requirements. Submitting 99397 to Original Medicare results in an automatic denial with no viable appeal pathway.

Medicare Advantage exception: Some MA plans do cover preventive physicals including CPT 99397 — always verify the specific plan benefits before scheduling or billing.

Medical Necessity, Coverage Rules & Payer Behavior in 2026

The way commercial payers handle CPT 99397 is largely favorable but it comes with conditions that practices frequently miss. Here is a payer-by-payer breakdown of what to expect in 2026:

Payer Type	CPT 99397 Coverage	Cost-Sharing	Billing Guidance
Original Medicare	Not covered — statutory exclusion	Full patient liability if billed incorrectly	Use G0439 for subsequent AWVs. An ABN does not create an exception to the exclusion for routine physicals.
Medicare Advantage	Varies by plan — many cover preventive physicals	Plan-specific; often $0 with in-network provider	Verify individual MA plan benefits through the provider portal before every preventive visit.
Commercial (ACA plans)	Most cover annually at 100% under ACA preventive mandate	Often $0 cost-sharing as preventive service	Confirm ACA preventive coverage applicability — some grandfathered plans are exempt.
BCBS (commercial)	Generally covers once per calendar year	Typically $0 for in-network preventive visits	Verify state-specific BCBS plan rules — coverage terms vary by region and plan type.
UHC/Aetna/Cigna	Cover when documentation clearly supports preventive intent	Varies by plan tier; often waived for preventive	Check payer portals annually — commercial payers update preventive benefit structures yearly.
Medicaid	State-dependent — most cover preventive visits	Generally $0 for preventive care	Verify state-specific Medicaid CPT crosswalk and fee schedule before billing.

PRO TIP — Eligibility Verification That Prevents Denials

Run a two-step eligibility check before every preventive visit: (1) Confirm the patient's plan covers preventive medicine visits (not just E/M services these are different benefit categories). (2) Confirm whether the patient has already had a preventive visit with any provider in the current benefit period. Many commercial plans apply frequency limits across the entire insurance network, not just your practice. A patient who saw another physician for a preventive visit six months ago may not be eligible for a second one at your office.

Documentation Requirements: What Your Note Must Prove

Documentation failures are responsible for the majority of CPT 99397 denials that reach our billing team. And it is almost never because the provider did not do the work. It is because the note does not prove the work was done. Payers reviewing a 99397 claim are looking for specific, documented evidence of each preventive medicine component — not a general indication that a checkup occurred.

The following checklist reflects what must be present in the medical record to support a CPT 99397 claim through commercial payer review and post-payment audit:

DOCUMENTATION CHECKLIST — CPT 99397 (All Sections Required)

SECTION 1 — COMPREHENSIVE HISTORY UPDATE

✓         Chief visit purpose documented as preventive/wellness (not problem-oriented)

✓         Updated medical history — all active diagnoses, recent hospitalizations, new diagnoses since last preventive visit

✓         Surgical history review — updated if any procedures occurred since last visit

✓         Family history — first-degree relatives; note any new family health events relevant to patient risk

✓         Social history — tobacco, alcohol, substance use, living situation, support system, activity level, diet patterns

✓         Review of systems — comprehensive, documented per body system, with age-specific attention areas noted

SECTION 2 — AGE-APPROPRIATE PHYSICAL EXAMINATION

✓         Vital signs — blood pressure, heart rate, respiratory rate, weight, height, BMI, temperature

✓         General appearance — nutritional status, overall wellness impression

✓         HEENT — head, eyes, ears, nose, throat; visual acuity screen or referral documentation

✓         Cardiovascular — rate, rhythm, murmurs, peripheral vascular assessment

✓         Pulmonary — breath sounds, respiratory effort

✓         Abdomen — organomegaly, masses, tenderness

✓         Musculoskeletal — joint mobility, gait assessment, fall risk observation

✓         Neurological — cognitive screen result documented (Mini-Cog, MoCA, or equivalent); reflexes as indicated

✓         Skin — integrity, lesions, wound healing

✓         Gender-specific — breast exam, prostate discussion, pelvic as clinically indicated

SECTION 3 — RISK FACTOR SCREENING

✓         Cognitive impairment screen — validated tool used, score documented (not just "cognition intact")

✓         Depression screen — PHQ-2 or PHQ-9 administered and score recorded

✓         Falls risk — history of falls in past 12 months, balance assessment, home hazard discussion

✓         Cardiovascular risk — blood pressure trend, cholesterol status, smoking history

✓         Diabetes screening — HbA1c or fasting glucose based on risk profile

✓         Osteoporosis — DEXA scan status, risk factor review (especially women 65+)

✓         Cancer screenings — colorectal, breast, lung, skin — status and plan documented

✓         Vision and hearing — screening performed or referral documented

SECTION 4 — COUNSELING & ANTICIPATORY GUIDANCE

✓         Health risk reduction counseling — diet, exercise, sedentary behavior reduction

✓         Tobacco/alcohol counseling documented with patient response

✓         Immunization review — influenza, pneumococcal, zoster, COVID booster status reviewed and updated or deferred with reason

✓         Fall prevention counseling — specific interventions discussed (exercise, home modifications, medication review)

✓         Medication safety — polypharmacy review documented, high-risk medications flagged

✓         Advance care planning — discussion documented or reason for deferral noted

✓         Patient education materials provided — noted in record

SECTION 5 — ORDERS, REFERRALS & CARE PLAN

✓         All laboratory orders listed with clinical rationale

✓         Imaging or diagnostic study orders documented

✓         Specialist referrals noted with reason for referral

✓         Follow-up plan — timeframe and trigger conditions documented

✓         Individualized preventive care plan documented (required for Medicare AWV; best practice for 99397)

WARNING — The Note Must Prove Each Section Separately

Do not blend preventive and problem-oriented documentation. If the note reads like an E/M visit for managing chronic conditions, a payer may deny or reprice the 99397 claim as a problem-oriented visit — reimbursed at a lower E/M rate. Every section of the preventive visit note should be clearly identifiable as preventive. If a separate problem was addressed, it must be documented in a distinct section of the note with its own assessment, findings, and decision-making. That is what supports Modifier 25 for a same-day E/M code.

Step-by-Step Billing Workflow for CPT 99397

Getting the code right is only part of the billing equation. The workflow around the claim from scheduling through submission determines whether you collect. Here is the sequence that eliminates the most common errors before they become denials:

STEP 01  —  Pre-Visit Payer Verification

Before the patient arrives, confirm three things through the payer portal: (1) Does this plan cover preventive medicine visits under CPT 99397? (2) Has the patient had a preventive visit with any provider in the current benefit year? (3) Is the patient on Original Medicare with no commercial supplement if so, route to the AWV workflow using G0439, not 99397. This three-minute check eliminates the majority of preventive billing denials.

STEP 02  —  Confirm Established Patient Status (3-Year Rule)

CPT 99397 requires the patient to be established — seen by a provider of the same specialty in your group within the past three years. If not, use CPT 99387 (new patient). Verify the last encounter date in your EHR at scheduling, not at billing. Catching a new/established mismatch after claim submission costs staff time that should not be spent that way.

STEP 03  —  Confirm Patient Age at Date of Service

CPT 99397 applies to patients who are 65 or older at the time of service. A patient who turns 65 the month after the visit should have been scheduled under 99396, not 99397. Run an automated age-check flag in your scheduling system that alerts staff when a patient falls within six months of their 65th birthday transitioning at the wrong time is an automatic denial.

STEP 04  —  Provider Uses Preventive Visit Template (Not Generic SOAP)

The documentation template drives the note quality. A preventive medicine template should prompt for each required section — comprehensive history update, age-appropriate exam, each risk assessment tool, counseling topics, and preventive orders. A generic SOAP note almost never captures all required preventive medicine elements and creates documentation gaps that surface as denials.

STEP 05  —  Separate Problem-Oriented Services with Modifier 25

If the provider also addresses a significant, separately identifiable medical problem during the visit — a new complaint, a worsening chronic condition, a medication adjustment requiring its own medical decision-making — bill an appropriate E/M code (99213–99215) in addition to 99397. Append Modifier 25 to the E/M code and ensure the problem-oriented portion of the note is documented distinctly with its own assessment and plan. Without Modifier 25, the E/M will be bundled into the preventive visit at no separate reimbursement.

STEP 06  —  Select Correct Primary Diagnosis Code

Use a preventive care Z-code as the primary diagnosis: Z00.00 (general adult medical exam without abnormal findings) or Z00.01 (with abnormal findings). Never use a chronic disease ICD-10 code as the primary diagnosis on a 99397 claim — it reclassifies the visit intent and may result in repricing or denial. Chronic condition codes can appear as additional diagnoses but not as the primary driver.

STEP 07  —  Pre-Submission Claim Scrub

Before the claim goes out, verify: correct CPT (99397 not 99387 for established patients), correct payer routing (never to Original Medicare without confirmed MA coverage), Modifier 25 on any same-day E/M code, primary diagnosis code is a Z-code, patient age and insurance ID are correct. One field error on a preventive claim is a denial that costs more to resolve than the claim is worth.

Modifier Reference for CPT 99397

Modifier	When to Apply	Billing Example
Modifier 25	A significant, separately identifiable E/M service is also provided on the same date	Patient presents for 99397 annual wellness. During exam, new knee pain reported; physician evaluates, orders X-ray, and counsels on anti-inflammatory options. Bill: 99397 + 99213-25 with separate diagnosis code for knee pain.
Modifier 33	Some commercial plans require this modifier to trigger ACA zero-cost-sharing for preventive visits	Check payer-specific policy — not universally required or recognized. When required, add to 99397 to indicate ACA-mandated preventive service.
No Modifier	Standard preventive visit with no separately identifiable problem addressed	Patient seen for annual wellness exam only — comprehensive preventive visit, no acute or chronic problem separately evaluated. Bill 99397 with Z00.00 or Z00.01.

Common Denial Reasons — With Specific Prevention Strategies

2026 Reimbursement Insights: What to Expect and What Affects It

Understanding what CPT 99397 realistically pays — and what factors determine whether you hit the high or low end of the range — is essential for revenue planning in a geriatrics practice. Here is the landscape in 2026:

Payer Type	2026 Rate Range	Cost-Sharing	Key Factors Affecting Payment
Commercial PPO/EPO	$120–$250	Often $0 under ACA preventive	Contract tier, geographic region, network status, documentation quality
Medicare Advantage	$100–$200 (if covered)	Plan-specific — often $0	Must verify individual MA plan. Not all cover 99397; some redirect to AWV codes.
BCBS Commercial	$140–$230	Typically $0 for in-network preventive	State and plan-specific; BCBS national plans vary significantly by region
Medicaid	$80–$140 (state-dependent)	Generally $0 for preventive	State fee schedule rate; verify before billing
Original Medicare	Not covered	100% patient liability	Never bill 99397 to Original Medicare
Self-Pay	Posted fee or negotiated rate	100% patient responsibility	Issue Good Faith Estimate per No Surprises Act before the visit

2026 REVENUE INSIGHT

The CY 2026 Medicare Physician Fee Schedule final rule (CMS-1832-F) confirmed favorable RVU treatment for office-based preventive services in non-facility settings. Work RVUs for the 99397 code family typically fall between 1.75 and 2.25, with geographic practice cost indices adjusting final payments. CMS data also confirms that practices billing preventive codes consistently — with correct documentation — see 12–18% higher annual collections compared to practices that default everything to problem-oriented E/M codes. Preventive visit billing is not administrative overhead. Properly captured, it is a significant revenue line.

The undercoding trap: Many geriatrics practices default to 99214 for annual wellness appointments because it is familiar. The documentation required is similar, but 99397 may reimburse at a comparable or higher rate depending on your payer contracts — and it captures the preventive visit benefit that your patients are entitled to under their plan. Defaulting to E/M coding for preventive visits means patients may owe a copay or deductible they should not owe, which creates patient satisfaction problems on top of billing inefficiency.

Real-World Billing Challenges in Geriatrics Practices

Billing rules on paper are clear enough. It is the day-to-day clinic environment where the errors actually happen. Here is where the revenue leaks occur in real geriatrics practices — and what they cost:

Scheduling and Front Desk Errors

•         Booking a Medicare patient for an "annual physical" without checking whether they should be scheduled for an AWV (G0439) — the provider performs a comprehensive preventive exam, the billing team submits 99397, and the claim is denied for non-covered service

•         Not capturing updated insurance information at annual visits a patient whose employer plan changed and who is now on Medicare-only gets a 99397 claim submitted with no coverage

•         Failing to check benefit year frequency limits — submitting a second preventive visit claim when the patient already had one at another practice six months earlier

Provider Documentation Habits

•         Completing a thorough preventive exam but writing a note structured like a problem visit — organized around diagnoses rather than preventive components, which causes payers to reprice the claim as E/M

•         Addressing a stable chronic condition during the preventive visit without documenting it separately — then not adding Modifier 25 to the E/M code because "it felt like part of the same visit"

•         Documenting "patient counseled on diet and exercise" without specifying what was discussed, how long counseling took, or what the patient's response was — this level of vagueness fails payer audit review

Coding and Billing Staff Gaps

•         Confusing 99397 (established patient 65+) with 99387 (new patient 65+) and 99396 (established patient 40–64) — these are the three most common age-and-status confusion errors in preventive medicine billing

•         Not tracking the transition from 99396 to 99397 when a long-time patient turns 65 — claims continue going out as 99396 for a patient now in the 65+ bracket, generating age-mismatch denials

•         Applying Modifier 25 too liberally — adding it to every preventive visit regardless of whether a separate E/M was actually performed, creating payer profiling risk and audit exposure

COMMON MISTAKE BOX — The Copy-Forward Documentation Trap

One of the most common and costly patterns we see in geriatrics practices is the use of EHR copy-forward features on preventive visit notes. The provider opens last year's annual exam note, copies it forward, makes a few changes, and signs. The result is documentation that is nearly identical across multiple visit dates — and payers' audit tools are specifically designed to flag this. Cloned documentation is not only a denial trigger. It is a compliance risk. CMS considers cloned notes a potential fraud indicator regardless of whether the clinical service was actually performed.

Each CPT 99397 visit note must be individualized to that specific encounter. Every section should reflect what was actually observed, discussed, and decided at that visit — not what was noted a year ago.

How MedCloudMD Eliminates These Challenges for Geriatrics Practices

The billing errors described above are not signs of a poorly run practice. They are signs of a billing workflow that was not built around the specific complexity of geriatrics patients, senior preventive care coding, and a predominantly Medicare-and-commercial payer mix. That is the exact problem MedCloudMD was designed to solve.

Frequently Asked Questions

Q1: Can I bill CPT 99397 and G0439 for the same patient?

No. These serve different payers and are mutually exclusive. G0439 is the Medicare Subsequent Annual Wellness Visit code for Original Medicare beneficiaries. CPT 99397 is a commercial insurance preventive code for established patients 65 and older. If a patient has both Medicare and a commercial Medigap supplement, the Medicare AWV (G0439) is the appropriate annual preventive service the supplement may pick up any residual cost-sharing, but you would not bill 99397 separately.

Q2: What is the key difference between CPT 99397 and CPT 99387?

Patient status. CPT 99387 is for new patients aged 65 and older those not seen by a provider of the same specialty in your group within the past three years. CPT 99397 is for established patients in the same age range. Using 99387 for an established patient (or 99397 for a new patient) is a billing error that generates a non-covered-service denial. This is one of the most common confusion points in senior preventive care billing.

Q3: What happens if I bill 99396 for a patient who turned 65 this year?

You will receive an age-mismatch denial. CPT 99396 covers established patients aged 40 through 64. Once a patient turns 65 at the date of service, CPT 99397 is the required code. This denial is automatic and cannot be overturned through appeal because it is a coding error, not a coverage dispute. The fix is prospective identify age transitions in advance and update coding accordingly.

Q4: Can a nurse practitioner or PA bill CPT 99397?

Yes. Nurse Practitioners and Physician Assistants may bill CPT 99397 under their own NPI at 85% of the Medicare rate for services they independently provide. For commercial payers, rates may vary by contract. If the service qualifies as incident-to billing under direct physician supervision within an established patient's plan of care, it may be billed at 100% under the supervising physician's NPI but incident-to requirements are strict and must be fully met. Incorrect incident-to billing is a significant compliance exposure area.

Q5: Do I need to use a specific screening tool for cognitive assessment?

There is no single mandated tool, but the cognitive screen must be validated and the result must be documented with a score or finding not just "cognition intact." Commonly accepted tools include the Mini-Cog, the Montreal Cognitive Assessment (MoCA), and the Mini-Mental State Examination (MMSE). Payers reviewing a 99397 claim for a patient 65 and older increasingly expect to see a documented cognitive screening result as part of the comprehensive preventive exam. Absence of a documented screen is a growing denial trigger in geriatrics preventive billing.

Q6: Can I bill advance care planning (CPT 99497) on the same day as CPT 99397?

Yes, and you should when it is clinically appropriate. CPT 99497 (first 30 minutes of advance care planning) can be billed on the same date as a preventive visit. Unlike the situation with E/M codes, CPT 99497 does not require Modifier 25 on the preventive code when billed together. The advance care planning session must be documented separately with the time spent, who was present, and what was discussed. Verify individual commercial payer policies on same-day ACP billing most cover it, but a handful require prior authorization or have frequency limits.

Q7: How do I handle a patient who wants to discuss a new symptom during their annual preventive visit?

You have two legitimate options. First, address the symptom briefly as part of the preventive visit if it requires no significant separate workup, it can be documented within the preventive note without triggering a separate E/M code. Second, if the symptom requires significant separate evaluation, decision-making, and its own assessment and plan, document it separately in the note and bill an appropriate E/M code (99213–99215) with Modifier 25 appended to that code. The key test: does the problem require a separately identifiable level of physician work beyond the preventive exam? If yes, Modifier 25 is appropriate. If the discussion is brief and no significant separate evaluation occurs, Modifier 25 is not.

About MedCloudMD: MedCloudMD is a U.S.-based medical billing and revenue cycle management company specializing in geriatrics billing services. Our AAPC-certified coding team and systematic claim workflows help geriatric practices reduce denials, maintain compliance, and capture the full revenue their clinical work earns. This blog is published for educational purposes and reflects 2026 CPT coding standards and payer guidance current as of the date of publication. Always verify current payer policies and CMS guidance for specific billing decisions.

Sources: AMA CPT Code Set 2026 | CMS Medicare Claims Processing Manual | CMS CY 2026 Physician Fee Schedule Final Rule (CMS-1832-F) | AAPC Preventive Medicine Coding Guidelines | CMS Annual Wellness Visit Coverage Guidance | AAFP Preventive Medicine Coding Resources