Can 99397 and G0439 Be Billed Together?

Medical billing and coding involves understanding specific rules for combining services. This article addresses whether CPT code 99397, representing Preventive Medicine Services for an established patient aged 65 or older, and HCPCS code G0439, the subsequent Annual Wellness Visit, can be billed together. We will explore the definitions of each service and the guidelines governing their simultaneous billing for accurate claims submission and compliance.

Understanding Preventive Medicine Services

CPT code 99397 describes a comprehensive preventive medicine evaluation and management service for an established patient 65 years or older. This service focuses on promoting overall health and preventing disease in asymptomatic individuals. It includes an age and gender-appropriate history, a physical examination, and counseling.

Components of this visit encompass a thorough review of medical, family, and social history, along with age-appropriate risk factor screening. Providers offer health counseling, anticipatory guidance, and interventions for risk factor reduction. The physical examination is tailored to preventive care, covering aspects such as vital signs, visual acuity, and cardiovascular and musculoskeletal checks.

CPT 99397 is generally reported once annually. However, Medicare does not cover CPT 99397, offering its own set of preventive services instead.

Understanding the Annual Wellness Visit

HCPCS code G0439 designates a subsequent Annual Wellness Visit (AWV) for Medicare Part B beneficiaries. This visit is distinct from a traditional physical examination and focuses on developing or updating a Personalized Prevention Plan of Service (PPPS). It is a no-cost benefit for eligible Medicare patients.

The AWV includes an update of the Health Risk Assessment (HRA), a review and update of the patient’s medical and family history, and a list of current providers and medications. It also involves screenings for cognitive impairment and depression, a reassessment of risk factors, and the establishment or revision of a screening schedule for the next five to ten years.

The AWV emphasizes prevention, care coordination, and ongoing risk factor surveillance. This service can be billed once per calendar year, at least 12 months after an initial AWV (G0438) or a previous G0439.

Billing Both Services on the Same Day

Directly billing CPT code 99397 and HCPCS code G0439 together for the same patient on the same day is generally not permissible for traditional Medicare. While some Medicare Advantage plans may cover CPT 99397, Medicare generally discourages billing both a wellness visit and a preventive visit on the same date due to potential overlap.

However, a significant, separately identifiable evaluation and management (E/M) service performed on the same day as an Annual Wellness Visit might be billable. This separate E/M service must address a new or existing problem requiring additional work beyond the scope of the AWV. For example, if a patient presents for their AWV and also has an acute complaint or a chronic condition requiring further evaluation, a separate E/M code (e.g., 99212-99215 for established patients) may be reported.

When billing a separate E/M service alongside an AWV, Modifier -25 must be appended to the E/M code. This modifier signifies that a significant, separately identifiable E/M service was provided by the same physician or other qualified healthcare professional on the same day as another procedure or service. Documentation must clearly support the distinct nature and medical necessity of the additional E/M service, ensuring it is not merely part of the preventive service.

CMS guidance indicates that if an abnormality or pre-existing problem is addressed during a preventive visit, requiring significant additional work for a problem-focused E/M service, both services can be reported. The E/M portion of the visit must be medically necessary to treat an illness or injury or to improve the functioning of a malformed body member. It is important to distinguish between the components of the AWV and the additional E/M service to avoid double billing. For instance, if elements of the history or exam were part of the AWV, they should not be included when determining the level of the problem-oriented E/M service.

Some commercial payers and Medicare Advantage plans may have different policies regarding the billing of CPT 99397 and G0439, sometimes allowing both under specific conditions. Providers should verify individual payer policies, as coverage can vary.

Essential Documentation for Billing

Thorough and accurate documentation in the patient’s medical record is important, particularly when services like a preventive exam and an Annual Wellness Visit are performed on the same day. The medical record must clearly delineate the components of each service to support their medical necessity and distinctness. This includes separate notes or clearly defined sections for the preventive physical examination elements and the AWV components.

Documentation should explicitly justify why both services were performed, highlighting that the additional E/M service addressed a significant, separately identifiable problem beyond routine preventive care. For instance, if an acute condition was managed, the history of present illness, physical exam findings, and the assessment and plan for that specific problem should be detailed. This clear separation helps demonstrate that the additional service was not bundled into the preventive visit.

Good documentation supports compliance with billing regulations and helps defend against potential audits. It should reflect the medical decision-making involved in addressing any separately identifiable conditions. Inadequate documentation can lead to claim denials, recoupments, or other compliance issues.