99397 CPT Code: Initial Hospital Care Billing and Documentation Guide

The 99397 cpt code is assigned to a complete preventive medicine visit (well child check-up) for established patients. It is for patients older than age 65 years. Patient status and age, type of service provided, payer rules, and documentation are all important to ensure accurate reporting.

This guide will help you choose and report 99397 cpt code, but avoid the confusion that may occur with problem-oriented visits and Medicare wellness services.

What Is the 99397 CPT Code?

CPT 99397 is for periodic comprehensive preventive medicine reevaluation and management of an established patient over age 65. Service consists of a history and examination, preventive counseling, risk reduction activities and appropriate orders, all tailored to an age and gender appropriate level.

This code is from the preventive medicine service family. It is not the same code as office or outpatient problem oriented E/M codes (99214). The main purpose is to prevent rather than evaluate and treat a particular illness. The AMA’s CPT materials describe preventive medicine services as comprehensive services designed around age and patient needs.

When Is 99397 the Correct Code?

Report 99397 cpt code for an encounter with an established patient for which a periodic comprehensive preventive evaluation is performed for an established patient at or after age 65. The documentation should support the preventive nature and scope of the service delivered. The code is not selected simply because the patient is older than 65. The encounter must actually represent the comprehensive preventive service described by the code.

Key selection factors include:

• The patient is established with the reporting clinician or practice.
• The patient is 65 years or older.
• The encounter is preventive in nature.
• The service includes the appropriate comprehensive preventive work.
• The medical record supports the services performed.

Preventive counseling was not required to make this problem-focused visit 99397. The primary service performed should be the same as the code family used by coders.

How Do Age and Patient Status Affect Coding?

Age and patient status determine which preventive medicine code belongs on the claim. The preventive medicine family separates new and established patients while also dividing age ranges.

The most important difference between a patient aged 65 or older and a younger patient is if the patient meets the CPT criteria for new or established patients. Generally, a new patient assigns coding to 99387 and an existing patient assigns coding to 99397. Do not select the code from age alone. Patient status must also be established from the applicable coding rules and documentation.

What Services Are Included in 99397 cpt code?

The preventive service involves a broad review of the patient’s health rather than one isolated complaint. The clinician evaluates age and gender appropriate health information and performs an appropriate examination. The service can also include preventive counseling and risk reduction interventions. Appropriate immunizations, laboratory studies, or diagnostic procedures may be ordered as part of the preventive encounter.

Typical preventive activities may include:

• Reviewing relevant health history
• Performing an appropriate preventive examination
• Discussing health risks
• Providing preventive counseling
• Addressing risk reduction
• Discussing age appropriate preventive needs
• Ordering appropriate laboratory or diagnostic services
• Ordering appropriate immunizations

The appropriate substance should be related to the patient situation and the clinician’s written work. Preventive care shouldn’t be done in isolation from a patient’s documented needs and be limited to a basic checklist.

What Services Require Separate Coding?

Some services performed during a preventive encounter may have their own coding requirements. The fact that a service occurs during a 99397 cpt code visit does not automatically make it part of the preventive code. For example, a separately identifiable problem-oriented E/M service may be reportable when its requirements are met. Certain diagnostic tests, procedures, vaccines, and administration services may also have separate codes.

Coders should determine whether the additional service has:

1. Its own reportable code.
2. Separate documentation requirements.
3. Applicable payer coverage.
4. Appropriate medical necessity.
5. Any bundling or modifier requirements.

This approach prevents unrelated services from being incorrectly absorbed into the preventive medicine code.

99397 vs 99214: What Is the Difference?

The main difference is the purpose of the encounter. CPT 99397 represents comprehensive preventive medicine for an established patient age 65 or older. CPT 99214 represents an established patient office or outpatient E/M service based on medical decision making or qualifying time.

A patient can receive preventive care and a medical problem treated. But the extra problem-oriented work has to be coded separately from the other E/M code, prior to reporting the other one.

Can 99397 cpt code and 99214 Be Billed Together?

They may be reported together if there is a significant, separately identifiable problem-oriented E/M service within the same encounter. The additional E/M service must involve work beyond the preventive service. The medical record should clearly demonstrate the separate evaluation and management performed.

If the requirements are met, the modifier 25 will be added to the problem-oriented E/M code. The modifier does not apply just because a diagnosis was made in the preventive visit. For example, a patient may receive a preventive examination while the clinician separately evaluates poorly controlled hypertension and changes treatment. The documentation must support that additional work independently.

How Does Medicare Treat 99397 cpt code?

Medicare treats routine preventive physical examinations differently from its covered preventive benefits. CMS states that routine physical examinations without a relationship to treatment or diagnosis of a specific illness, symptom, complaint, or injury are not covered under Medicare. 99397 cpt code falls within the comprehensive preventive medicine code range that Medicare identifies as noncovered when used for routine preventive examinations.

This means coders should not treat 99397 as interchangeable with Medicare’s covered wellness benefits. CMS also provides specific billing instructions when a medically necessary covered visit occurs during the same encounter as a noncovered preventive medicine service. Payer-specific policies outside Medicare can differ. Commercial plans should therefore be checked against their current preventive benefit and coding policies.

What Medicare Codes Apply Instead?

There are specific HCPCS codes designated to help Medicare cover preventive programs. Initial Physical Examination for prevention (medical history, physical exam, counseling, diagnosis, and preventive services) is G0402 and Annual Wellness Visit (medical history, physical exam, counseling, diagnosis, preventive services) is G0438 and G0439.

Each of these codes has certain eligibility, frequency and service requirements for Medicare. Medicare eligibility should not be the sole reason to use them in lieu of CPT 99397.

To prevent billing for Medicare IPPE and AWV services, CMS specifically advises providers to exclude services performed under this category from billing for CPT 99381 through 99397.

How Does an AWV Differ From 99397?

An Annual Wellness Visit is a preventive medicine service with a specific, defined Medicare structure, which is not a comprehensive preventive medicine service. The AWV focuses on a health risk assessment and/or the development or update of a personalized prevention plan.

CMS lists certain AWV elements, such as health risk assessment information, medical and family history, measurements, cognitive assessment, screening recommendations, and personal prevention planning. The AWV is therefore not simply another name for a routine physical examination. Coding should follow the actual service and the payer’s applicable requirements. It is particularly important for Medicare patients as CMS mandates a G0438 or G0439 for covered AWV services.

What Documentation Supports 99397 cpt code?

Documentation should show the clinician actually performed the comprehensive preventive service (code). The record should convey to another reviewer what the encounter is about.

Useful documentation elements include:

• Patient’s established status
• Relevant age and preventive history
• Appropriate health history
• Preventive examination findings
• Risk assessment and counseling
• Preventive recommendations
• Risk reduction interventions
• Orders made during the encounter
• Additional services separately evaluated
• Medical necessity for separately reported services

The documentation should reflect actual services rather than relying on templated language alone. Templates can support consistency, but they should accurately represent the work performed during that encounter.

Does 99397 Have a Time Requirement?

99397 cpt code is not selected using the time thresholds that apply to many office and outpatient E/M services. The code is part of the preventive medicine family, so coders should focus on the nature and scope of the preventive service.

This differs from codes such as 99212 through 99215, where office E/M level selection can use total time on the date of service when applicable. Therefore, adding a large number of minutes to a 99397 cpt code note does not automatically justify the code. The documentation should instead demonstrate that the comprehensive preventive service was actually provided.

Can Screening Tests Be Reported Separately?

Screening services can involve separate coding when the service has its own applicable code and coverage requirements. The preventive encounter itself does not automatically determine how every resulting test is billed. For Medicare, CMS distinguishes screening services from diagnostic services based on the purpose of the service. Screening generally concerns asymptomatic patients, while diagnostic services can address symptoms, conditions, or treatment monitoring.

Coders should therefore review the reason for the test, applicable diagnosis coding, payer coverage, and any frequency limitations. The ordering of a laboratory or diagnostic service during 99397 cpt code does not guarantee separate payment. Coverage and medical necessity remain important considerations.

How Are Vaccines Handled With 99397 cpt code?

Vaccines may involve separate product and administration coding when the applicable requirements are satisfied. The preventive visit itself should not be assumed to include every vaccine-related service. The claim may require coding for the vaccine product and its administration. Coverage depends on the patient’s payer, benefit structure, vaccine type, and applicable policy.

For Medicare patients, preventive vaccine coverage can have specific rules that differ from general preventive medicine billing. Coders should verify the applicable Medicare benefit before assigning the final codes. Documentation should support the vaccine provided, administration, and any relevant counseling or other separately reportable service.

Which Modifiers May Apply to 99397 cpt code?

Modifier use depends on the specific circumstances surrounding the encounter. A modifier should not be added simply to increase reimbursement or because multiple services appear on one claim. The most relevant scenario is when the issue is a problem-oriented E/M service that has been separately identifiable with the preventive service.

The modifier 25 is typically used to indicate that the additional E/M is performed with the same patient and is in connection with the same condition as the E/M, but has been performed at the same encounter. The documentation should show that the additional work was medically necessary and distinct from the preventive service. Always review payer-specific modifier policies because commercial insurers can apply requirements that differ from Medicare.

What Are the 2026 RVUs for 99397?

The 99397 cpt code RVU data in the 2026 Physician Fee Schedule are as follows:

The national non-QP conversion factor for 2026 is around $33.40. According to CMS, payment under the Physician Fee Schedule is based on RVUs, geographic adjustments and the conversion factor.

Using a national GPCI of 1.000, the 2026 calculation produces approximately:

• Non-facility: 4.16 × $33.4009 = $138.95
• Facility: 2.55 × $33.4009 = $85.17

These figures are national baseline calculations, not guaranteed claim payments. Actual Medicare payment depends on locality-specific GPCIs and other applicable payment adjustments.

How Is 99397 cpt code Payment Calculated?

Medicare payment is not based on the total RVU alone. The individual work, practice expense, and malpractice components are adjusted using locality-specific geographic practice cost indices. The general calculation applies the appropriate GPCI to each RVU component before multiplying the result by the conversion factor. CMS describes this relationship as part of the Physician Fee Schedule payment methodology.

This means two claims for the same CPT code can have different Medicare allowed amounts when they are furnished in different localities. Ultimately, there are other claim level factors that may impact ultimate reimbursement. So the national 2026 figure is a guideline and shouldn’t be taken as a fixed payment figure.

What Common Errors Affect 99397 cpt code Claims?

Several mistakes can cause incorrect code selection or payment problems. Most involve confusing preventive medicine with another service category.

Common errors include:

• Reporting 99397 cpt code for a new patient
• Selecting 99397 cpt code for patients under age 65
• Using 99397 cpt code for a problem-focused encounter
• Billing 99397 for a Medicare AWV
• Adding modifier 25 without separate E/M work
• Reporting unsupported screening services
• Ignoring payer-specific preventive coverage
• Using documentation that does not support the service
• Assuming all vaccines are included in the preventive code
• Treating age alone as sufficient code-selection support

A claim review should examine the encounter purpose before reviewing secondary services. This helps prevent the same documentation from being interpreted as both preventive and problem-oriented work.

99397 cpt code Coding Example: From Visit to Claim

A longstanding, 72-year-old patient comes in for a full preventive exam. The clinician reviews the preventive history, conducts an appropriate examination, discusses risk reduction and orders age appropriate preventive testing. The encounter is a preventive encounter and is for an established patient age 65 years or older. The code for preventive medicine is 99397 cpt code.

If the clinician also considers uncontrolled hypertension a medical condition, then manage it separately. Clinicians examine conditions, evaluate current therapy and change medicines. When a significant and separately identifiable E/M service is documented in the record, the appropriate problem-oriented E/M code can be used in addition to modifier 25. The important coding point is that the additional E/M service must represent work beyond the preventive service. Simply documenting hypertension in the medical history would not automatically justify another E/M code.

99397 cpt code Claim Review Checklist

Before submitting a 99397 cpt code claim, review the encounter in this order:

1. Confirm the patient is established.
2. Confirm the patient meets the age requirement.
3. Verify that the encounter was preventive in nature.
4. Review the documented preventive services.
5. Confirm the record supports the comprehensive service.
6. Check whether separately reportable services were performed.
7. Review modifier 25 requirements when another E/M is billed.
8. Check Medicare coverage when the patient has Medicare.
9. Verify screening and vaccine coding separately.
10. Review payer-specific coverage and billing rules.
11. Confirm diagnosis coding supports separately reported services.
12. Compare the claim against the medical record before submission.

This sequence separates code selection, service validation, additional coding, and payer review. It can help coders identify problems before the claim reaches the payer.

Conclusion

The 99397 CPT code is for comprehensive preventive medicine services for an established patient aged 65 years and older. To report correctly, age is not the only piece of information needed. Patient status, encounter purpose, documented preventive work, separately reportable services and payer requirements should be assessed by coders. Medicare claims warrant special attention because routine preventive exams and Medicare wellness benefits are separated out into different coding pathways.

The 99397 cpt code has 2.00 work RVUs, 2.04 non-facility practice expense RVUs, 0.43 facility practice expense RVUs and 0.12 malpractice RVUs for 2026 payment analysis. Actual payment must be confirmed to the applicable Medicare fee schedule as the actual national baseline will be different by setting and locality.

Frequently Asked Questions About 99397