CPT 99397: Preventive visit, established, age 65+
What this code means, what it should cost, and how to dispute an overcharge.
Fair Price Reference
What is CPT 99397?
Your annual wellness exam for an established patient age 65+. Often called the 'Annual Wellness Visit' for Medicare patients, though Medicare uses its own codes (G0438/G0439) for the Medicare Annual Wellness Visit. 99397 is the traditional preventive visit code used by commercial insurance.
Typical setting: Primary care office, geriatrics, internal medicine.
What CPT 99397 should cost
The Centers for Medicare & Medicaid Services (CMS) pays approximately $119 for CPT 99397 under the 2025 Physician Fee Schedule. This is what the federal government has determined is a reasonable payment for this service.
Private insurance typically pays 1.2–1.8x Medicare rates ($143–$214). Hospital chargemaster prices for CPT 99397 often range from $190 to $600 — a markup of 1.6x to 5x over Medicare.
Reality check: Medicare pays about $119 for 99397. Medicare patients should verify whether G0438/G0439 (AWV) codes would result in lower out-of-pocket cost. Commercial patients should pay $0 under ACA preventive rules.
Common overcharges on CPT 99397
For Medicare patients: if your provider billed 99397 instead of G0438/G0439, you may owe a copay that wouldn't apply under the Medicare Annual Wellness Visit benefit. For commercially insured patients: same double-billing risk as other preventive codes — watch for a separate 99214/99215 office visit charge on the same date.
About Preventive billing
Preventive visit codes (annual physicals, well-child visits, wellness exams) cover a comprehensive head-to-toe evaluation at defined age intervals. Under the ACA, many preventive services must be covered at 100% with no cost-sharing when performed by an in-network provider — but billing errors can turn a free annual physical into a surprise bill.
Request visit notes. If the provider billed both a preventive code and an office visit code, the documentation must show a distinct, significant clinical problem addressed beyond the scope of the preventive visit. If the provider simply discussed an existing condition, refilled medications, or answered routine questions, the separate E&M charge is not justified.
How to dispute a CPT 99397 overcharge
- Request the itemized bill. You are entitled to a detailed line-by-line bill showing every CPT code billed. Ask in writing.
- Compare to Medicare allowable. If the charge exceeds 150% of Medicare ($179), you have grounds to dispute.
- Request documentation. For E&M codes, ask for the visit note. For procedures, ask for the operative report. The documentation must justify the code billed.
- Send a formal dispute letter. Cite the specific discrepancy between the documentation and the code. Reference Medicare rates and NCCI edits where applicable.
- Follow up in writing. Give the provider 30 days to respond. If they don't, escalate to the state attorney general and insurance commissioner.
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