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CPT 99398 in Medical Billing: Preventive Visit for Ages 65+

Preventive care becomes more important with age especially once a patient crosses 65. For medical billers, coders, and providers, understanding how CPT 99398 in Medical Billing works is essential for clean claims, accurate payments, and strong compliance.

Over the years, I’ve handled thousands of preventive visits, including CPT 99398, and I’ve seen many clinics lose revenue simply because they misunderstand one thing: the difference between preventive exams and Medicare’s Annual Wellness Visit (AWV).

CPT 99398 is a commercial-insurance preventive code for adults 65+, and when billed correctly, it significantly boosts reimbursement and reduces unnecessary claim denials. This blog will walk you through everything: documentation, billing rules, payer-specific requirements, and real-life scenarios from my own billing experience.

To support deeper learning, I will also add helpful internal links to related codes like

and essential E/M codes such as

Let’s break it all down clearly.

What Is CPT 99398?

CPT 99398 is used for an adult preventive visit for patients aged 65 and older under commercial insurance or Medicare Advantage plans (NOT traditional Medicare).
This code is part of the adult preventive series, similar to:

What Counts as a Preventive Visit for Ages 65+

A preventive exam includes a full head-to-toe evaluation and risk-based screenings such as:

  • vision

  • hearing

  • fall risk

  • cognitive evaluation

  • depression screening

  • lifestyle and functional assessments

  • chronic disease prevention

It must focus on health maintenance, not problem-based care.

Covered Screenings and Assessments

Typical screenings in CPT 99398 documentation:

  • Tobacco/alcohol use

  • Nutrition & exercise

  • Blood pressure, BMI

  • Fall risk

  • Cognitive assessment

  • Safety screening

  • Cholesterol & diabetes risk

  • Immunization review

  • Cancer screening recommendations

When Additional Services Require Separate Billing

If the patient presents with a new or worsening problem, you may bill an E/M code with modifier 25.

Example:
Patient comes for preventive exam but also reports dizziness or back pain → provider performs a medically necessary problem-focused exam → bill CPT 99398 + 99213-25.

Internal reference for E/M levels:

Documentation Requirements for CPT 99398

Using CPT 99398 in medical billing requires precise documentation. Missing one required element often leads to claim denials.

Comprehensive Exam Elements

Documentation must include:

  • Complete medical history

  • Past medical/surgical history

  • Medication review

  • Family history

  • Social history

  • Lifestyle habits

  • Full system-based physical exam

  • Personalized preventive plan

Age-Specific Screenings (65+)

Providers must include:

  • Fall risk

  • Cognitive screening (Mini-Cog, MoCA, etc.)

  • Hearing loss check

  • Mobility assessment

  • Functional status evaluation

Immunization Updates

Documentation must include a review of:

  • Flu vaccine

  • Pneumococcal vaccine

  • Shingles vaccine

  • COVID booster (if applicable)

Required Diagnosis Codes for CPT 99398

Use preventive ICD-10 codes:

  • Z00.00 – Adult preventive visit, no abnormal findings

  • Z00.01 – Adult preventive visit, with abnormal findings

These codes signal payers that the visit is preventive, not problem-based.

Billing Guidelines for CPT 99398

Coverage Rules for Commercial Plans

Most commercial payers cover one preventive visit per year with zero patient cost-sharing.
Examples include:

  • Aetna

  • Cigna

  • BCBS

  • UnitedHealthcare

  • Humana (commercial)

  • Kaiser

Medicare Replacement / Medicare Advantage Considerations

This is the area where clinics lose revenue.

I had a clinic last year where nearly 40 CPT 99398 claims were denied, because they mistakenly billed the AWV code (G0439) for a Medicare Advantage patient whose plan required CPT 99398 instead.

Lesson:
Always verify whether the plan covers CPT 99398 or AWV coverage varies by payer.

Frequency: How Often CPT 99398 Can Be Billed

Most payers allow:

  • Every 12 months

  • Occasionally every 365 days

  • Some allow once per calendar year

Verify through eligibility tools.

When to Use Modifier 25

Add modifier 25 when:

  • A significant problem-based evaluation is performed

  • Documentation clearly supports it

  • The provider addressed a new or worsening condition

Example:
CPT 99398 + 99213-25

Reimbursement for CPT 99398 in 2025

National Average Reimbursement

The average nationwide reimbursement is $155–$260, depending on:

  • Payer

  • State

  • Network contract

  • Provider type

Commercial plans generally pay higher than Medicare Advantage.

What Payers Include or Exclude

Included:

  • Counseling

  • Full preventive exam

  • Screenings

  • Immunization review

Not included (bill separately):

  • Labs

  • Vaccines

  • Diagnostic tests

  • Chronic disease evaluation (use E/M)

Avoiding Common Denials

Top CPT 99398 claim denial reasons:

  1. Wrong diagnosis code (used problem-based instead of Z-code)

  2. Billing CPT 99398 when plan only covers AWV

  3. No documentation for screenings

  4. Billed preventive exam too early (frequency exceeded)

  5. Modifier 25 missing

CPT 99398 vs Annual Wellness Visit (AWV)

This is the #1 confusion in senior preventive billing.

Preventive Exam vs AWV Differences

Feature CPT 99398 (Preventive Exam) AWV (G0438/G0439)
Covered by Commercial & MA Medicare Part B
Physical exam Yes No full physical exam
Age 65+ 65+
Frequency Yearly Yearly
Diagnosis Z00.00 / Z00.01 Z00.00 only

What Doctors Often Misunderstand

Many providers think AWV is a preventive exam it’s not.

AWV is only a health-risk assessment + plan, not a physical exam.
CPT 99398 requires a full hands-on exam.

Billing Both Correctly

You cannot bill CPT 99398 and AWV on the same day.

But you can bill CPT 99398 on one date and AWV on another, depending on payer coverage.

Final Summary

CPT 99398 is essential for preventive exam coding for seniors, and mastering it ensures clean claims and strong reimbursement. Using CPT 99398 in medical billing correctly requires:

  • Complete documentation

  • Accurate diagnosis codes

  • Understanding payer rules

  • Correct use of modifier 25

  • Knowing the CPT 99398 frequency limits

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FAQs

1. What is CPT 99398 in medical billing?

CPT 99398 in medical billing is a preventive visit code used for adults aged 65+, covering screenings, routine exams, and preventive counseling.

2. How often can CPT 99398 be billed?

Most insurers allow one preventive visit once every 12 months, depending on the patient’s plan.

3. Is CPT 99398 the same as a Medicare AWV?

No. Medicare AWV uses G0402, G0438, or G0439. CPT 99398 applies to commercial and Medicare Advantage plans, not Original Medicare.

4. What documentation is needed for CPT 99398?

A full preventive exam, history, cognitive and risk screening, counseling, and age-appropriate testing must be documented.