| Category | Amount |
|---|---|
| Medicare Allowed Rate What Medicare approves for this service | $142.56 |
| Typical Billed Amount What providers commonly charge | $210 – $460 |
| Potential Markup How much more you might pay vs. Medicare rate | 223% above Medicare |
What CPT Code 99397 Means
CPT code 99397 represents a comprehensive annual physical exam for established patients who are 65 years of age or older. This is your yearly wellness visit where your doctor reviews your overall health, updates your medical history, performs a physical examination, and discusses preventive care measures appropriate for your age group.
Your doctor will use this code when you're an established patient, meaning you've been seen by this provider or someone in their practice within the past three years. The visit focuses on preventing health problems rather than treating existing symptoms or illnesses.
This type of visit typically includes reviewing your medications, discussing screenings like colonoscopies or mammograms, updating vaccinations, and addressing age-related health concerns such as fall prevention, cognitive health, and managing chronic conditions.
What to Expect on Your Bill
When you receive your bill or explanation of benefits, you'll see CPT code 99397 listed for your annual physical. The typical charge for this service ranges from $210 to $460, depending on your healthcare provider and geographic location.
If you have Medicare, the standard reimbursement rate for this service is $142.56. However, what you actually pay depends on your specific insurance coverage. Many insurance plans, including Medicare, cover annual preventive visits at 100%, meaning you may owe nothing out of pocket.
The bill should clearly indicate this was a preventive care visit. If you discussed new symptoms or health problems during your physical, you might see additional codes on your bill for those separate issues, which could result in additional charges.
How to Verify Your Bill is Correct
First, confirm that the date of service matches when you had your annual physical, and verify that you are indeed 65 or older. If you're under 65, the correct code should be 99396 instead. Also, make sure you're listed as an established patient - if this was your first visit with this provider, a different code should be used.
Check that the charge falls within the typical range of $210-$460. If the amount seems unusually high, contact your provider's billing department to ask for an itemized explanation. Remember that if additional services were provided during your visit beyond the routine physical, those may appear as separate line items.
If you believe there's an error, start by calling your healthcare provider's billing office with your specific concerns. They can review your visit notes and explain the charges. If you're still not satisfied, you can contact your insurance company to request a review of the claim.