Can I bill 99397 (Preventive Medicine Counseling and/or Risk Factor Reduction Intervention) for a Medicare wellness exam?

Medicare Wellness Exam Billing

No, you cannot bill CPT code 99397 for a Medicare wellness exam—Medicare does not cover the 99381-99397 preventive medicine codes and instead requires you to use the Medicare-specific wellness visit codes G0438 (initial visit) or G0439 (subsequent visit). 1

Correct Medicare Wellness Visit Codes

Use Medicare-specific G-codes, not standard preventive care codes:

• G0438: Initial Medicare Annual Wellness Visit (AWV) for beneficiaries who have not had an AWV within the past 12 months 2
• G0439: Subsequent Medicare Annual Wellness Visit for beneficiaries who have had an AWV within the past 12 months 2

The 99381-99397 series are standard preventive care codes used for commercial insurance and non-Medicare patients, but Medicare explicitly does not reimburse these codes for wellness visits. 1

Key Differences Between Standard Preventive Codes and Medicare Wellness Visits

Medicare wellness visits have different requirements than traditional preventive exams:

• Medicare AWVs focus on health risk assessment, personalized prevention planning, and screening for cognitive impairment rather than comprehensive physical examination 3, 4
• No comprehensive physical exam is required beyond blood pressure measurement 5
• The visit emphasizes updating medical and medication histories, assessing cognitive and physical function, and recommending preventive services 2
• Medicare provides these visits at no cost to beneficiaries enrolled in Part B 4

Billing for Additional Services During Medicare Wellness Visits

You can bill additional codes alongside G0438/G0439 when separately identifiable services are provided:

• Use modifier 25 on the wellness visit code when billing a separate evaluation and management service on the same day 1
• Developmental or cognitive screening (CPT 96110) can be added to the wellness visit with appropriate modifier 1
• If the visit becomes complex and requires significant problem-focused evaluation beyond the wellness visit scope, you may bill an appropriate E/M code (99212-99215) in addition to the wellness visit code with modifier 25 6, 1

Common Billing Pitfalls to Avoid

Critical errors that will result in claim denials:

• Do not use 99381-99397 codes for Medicare patients—these will be rejected 1
• Do not confuse the Initial Preventive Physical Examination (IPPE, code G0402) with the Annual Wellness Visit—the IPPE is only for beneficiaries within the first 12 months of Medicare Part B enrollment 7
• Always append modifier 25 when billing separately identifiable E/M services on the same day as the wellness visit 1
• Ensure documentation supports the health risk assessment and personalized prevention plan required for G0438/G0439 2

Financial Viability

Medicare wellness visits using G0438/G0439 are financially viable:

• Practices have demonstrated positive net income from pharmacist-delivered Medicare wellness visits using these codes 2
• The visits can be performed by physicians or other licensed practitioners working under physician supervision 8
• Medicare Advantage plans show higher utilization rates of wellness visits compared to fee-for-service Medicare, suggesting opportunities for increased revenue through proper coding and patient outreach 4