Summary & Overview
CPT 99397: Periodic Preventive Medicine Reevaluation for Established Adults
Headline: CPT 99397 Targets Comprehensive Preventive Care for Established Adults
Lead: CPT 99397 denotes a comprehensive periodic preventive medicine reevaluation and management visit for established adult patients focused on history-taking, physical examination, counseling, risk-reduction, and ordering necessary tests. This code supports preventive care delivery and coding consistency across outpatient primary care settings.
What the code represents and why it matters: CPT 99397 specifies an annual-type preventive encounter for adults that bundles age- and gender-appropriate assessment, counseling, and preventive screening orders. Nationally, the code is central to primary care practices' delivery of preventive services, quality measurement, and alignment with preventive care guidelines.
Key payers covered: Analysis includes coverage and coding context for major national payers: Aetna; Blue Cross Blue Shield; Cigna Health; and UnitedHealthcare.
Overview of what readers will learn: The publication outlines clinical scope and billing context for CPT 99397, compares it to adjacent preventive codes for established patients, summarizes common coverage considerations and modifier usage, and highlights typical office-based implementation. It provides benchmarks for utilization patterns, common clinical scenarios that fit the code, and policy considerations relevant to preventive care coding.
Data notes: Data not available in the input for any payer-specific rates or state-limited policies.
CPT Code Overview
CPT 99397 is a periodic comprehensive preventive medicine reevaluation and management visit for an established adult patient. The service includes an age- and gender-appropriate history, comprehensive examination, counseling/anticipatory guidance, risk factor reduction interventions, and ordering of laboratory or diagnostic procedures as indicated.
Service Type: Preventive Medicine Evaluation and Management
Typical Site of Service: Office (POS 11)
Clinical & Coding Specifications
Clinical Context
A 68-year-old established patient presents to a primary care office for an annual periodic preventive medicine evaluation. The visit is scheduled in the office (POS 11) with a family medicine or internal medicine clinician. The clinician completes an age- and gender-appropriate history, a focused physical examination, counseling and anticipatory guidance (including fall risk, immunizations, and lifestyle counseling), and orders age-appropriate screening tests such as colon cancer screening and cardiovascular risk screening. The encounter is documented as a preventive medicine visit and coded as 99397. If abnormal findings are identified during the examination or screening review, the clinician documents the findings and any follow-up plans within the same visit.
Coding Specifications
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Modifiers:
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25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service — Use when a separate E/M service distinct from a procedure or other service is provided on the same calendar day and is documented as a distinct, significant evaluation and management encounter in addition to the preventive service. -
33: Preventive Services — Use to indicate the service is a preventive service when required or accepted by the payer; identifies the visit as preventive in nature.
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Associated provider taxonomies:
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2084P0800X— Family Medicine (represents Family Medicine practitioners) -
207P00000X— Internal Medicine (represents Internal Medicine practitioners)
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Related Diagnoses
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Z00.00— Encounter for general adult medical examination without abnormal findings- Clinical relevance: Documents a routine preventive adult exam when no abnormal findings are identified; appropriate for a preventive medicine visit coded as
99397when the exam is normal.
- Clinical relevance: Documents a routine preventive adult exam when no abnormal findings are identified; appropriate for a preventive medicine visit coded as
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Z00.01— Encounter for general adult medical examination with abnormal findings- Clinical relevance: Used when the preventive examination identifies abnormal findings that require documentation and possible follow-up within the preventive encounter.
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Z13.6— Encounter for screening for cardiovascular disorders- Clinical relevance: Indicates cardiovascular screening activity (risk assessment, blood pressure review, lipid screening) performed or ordered as part of the preventive visit.
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Z12.11— Encounter for screening for malignant neoplasm of colon- Clinical relevance: Indicates colorectal cancer screening (orders for colonoscopy, fecal testing) initiated or reviewed during the preventive medicine visit.
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Z13.89— Encounter for screening for other disorder- Clinical relevance: Captures other screening activities performed or ordered during the preventive visit (for example, screening for conditions not otherwise specified) that are part of the preventive care workflow.
Related CPT Codes
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99395- 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- Relationship:
99395is the lower-age-range periodic preventive visit in the same family of codes and may be used for younger established patients for whom99397would not be age-appropriate. It serves as an alternative depending on the patient’s age.
- Relationship:
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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- Relationship:
99396represents the intermediate age range within the periodic preventive code set and may be used instead of99397for patients whose age falls into that bracket. It serves as an age-based alternative within the preventive medicine E/M series.
- Relationship:
National Reimbursement Benchmarks
National mean allowed rates show that Medicare is substantially lower than the BUCA average commercial mean. BUCA (the blended commercial benchmark) posts a mean of $149.50 while Medicare is represented here as $0.00 in the input, indicating no Medicare mean rate was provided in the dataset.
Dispersion measured by the interquartile spread (P75 − P25) varies across payers. UnitedHealth Group has one of the widest spreads (approximately $104.00), followed by Cigna (about $103.00), indicating greater variability in allowed rates. Aetna and Blue Cross Blue Shield display tighter distributions (Aetna spread ≈ $66.50; BCBS spread ≈ $58.57), reflecting more consistency around their central values. The table and chart below present the full percentile and mean breakdown.
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