CPT Code 99397: Preventive Medicine Visit, Established Patient, Ages 65 and Older

What is the 99397 CPT code all about?

CPT code 99397 is one of the CPT codes for comprehensive preventive medicine services. CPT code 99397 designates a comprehensive preventive medicine evaluation and management service for established patients aged 65 years and older.

This code encompasses the following services appropriate for the age of the patient:

• Age-appropriate history
• Age-appropriate examination
• Counseling
• Anticipatory guidance
• Risk factor reduction interventions

These services are geared to prevent disease, injury, and disability of seniors by identifying health risks way before they become apparent or adverse, and implement preventive strategies to minimize the potential negative effects of such problems should they happen.

During such sessions, attending physicians will conduct assessments to examine the patient's cognitive and functional status, immunization status, fall risk, undergo screenings for cancer and musculoskeletal issues common for their age, medication review, and advance care planning.

Providers handling these patients will focus on addressing chronic medical conditions through preventive care.

CPT code 99397 documentation requirements

Before filing this code for billing, it's important to have the necessary documentation ready. For this particular CPT code, you need the patient's age and gender-appropriate history, examination, counseling, anticipatory guidance, risk factor reduction interventions, immunization, and any necessary laboratory diagnostic procedures. Comprehensive examinations and the preventive intent behind them should be recorded, too.

Another rule to follow is that documentation should not contain ambiguous language to lower the risk of audits and reimbursement denial.

CPT code 99397 billing guidelines

Make sure to adhere to preventive medicine coding guidelines:

• Make sure the patient is aged 65 or older, or you can't use this code at all.
• This code can't be used alongside G0438 or G0439, both of which are codes for Medicare's Annual Wellness Visit.
• Speaking of Medicare, that insurance provider will not reimburse this CPT code, but most providers do. It's best to discuss this with the provider before billing to avoid unexpected denials.
• Just in case you detect an acute or chronic condition during the preventive visit, especially conditions that require further examination and additional treatment, please bill a separate E/M code with Modifier 25 appended. Make sure to clearly document the separate components of care, too.