Primary Care Coding Alert

Question: We have been using CPT^® codes 99396 or 99397 for preventive medicine visits/annual wellness visits for patients on Blue Cross Medicare Advantage plans, but we have recently been getting denials and patients are being billed for the services. Are these codes covered, or should we be using G0402 or G0438/G0439?

California Subscriber

Answer: Payment for 99396 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years) or 99397 (… 65 years and older) may depend on the Blue Cross Medicare Advantage plan in question.

Anthem Blue Cross, for example, recognizes the services and state that there “are no out-of-pocket expenses for the member … when the routine physical is completed by an in-network provider in an HMO and/or PPO plan” (see www11.anthem.com/ca/shared/f2/s2/t1/pw_g329161.pdf). Traditional Medicare, however, does not cover 99396 and 99397, and other Blue Cross Medicare Advantage plans may follow traditional Medicare in this regard.

These services are not the same as G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment), which is commonly known as the Welcome to Medicare visit. These services are also distinct from G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit) and G0439 (… subsequent visit).

The initial preventive physical examination (IPPE) and annual wellness visit (AWV) are described as preventive, but they vary in their content. For instance, they do involve a physical exam, but clinical responsibilities for the IPPE and AWV involve more counselling and education than might occur in 99396/99397. Codes 99396/99397, on the other hand, tend to involve a more thorough physical exam.

In fact, you can actually bill for an IPPE or an AWV in addition to 99396/99397, providing you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the 99396/99397 if it is performed on the same day.