In family medicine, keeping up with senior patients' health through routine check-ups is key to catching issues early and promoting wellness. But billing CPT 99397—the code for comprehensive preventive reevaluation in patients 65 and older—can trip you up with Blue Cross Blue Shield (BCBS) if you're not dialed in on the details. If you're hunting for "BCBS CPT 99397 billing guidelines" or "preventive exams family medicine BCBS 2025," this guide walks you through the basics, common pitfalls, and fixes to help your practice get reimbursed smoothly without the back-and-forth.

What Is CPT 99397 and When Does BCBS Cover It?

CPT 99397 covers a periodic comprehensive preventive medicine visit for an established patient aged 65 or older. It includes an age- and gender-appropriate history, exam, counseling on risk factors, and ordering labs or tests—think annual physicals focused on prevention, not problem-solving.

BCBS commercial plans typically cover this once per calendar year as a preventive service, often with no cost-sharing for the member if it's purely preventive. For Medicare Advantage plans under BCBS, it might align with annual wellness visits, but check your specific plan—some use it alongside G0438/G0439 for wellness. Always verify benefits via the provider portal, as coverage can vary by state or plan type.

2025 Billing Guidelines for CPT 99397 with BCBS

For 2025, BCBS follows standard CPT instructions: Bill 99397 for preventive reevals in seniors, ensuring the service reflects comprehensive history, exam, and guidance without addressing acute issues (those need a separate E/M code with modifier -25). Use ICD-10 codes like Z00.00 (general adult exam without abnormal findings) to support it.

Key tips:

• Frequency: One per year; extras may deny as duplicate.
• Documentation: Note the preventive focus—counseling on diet, exercise, or screenings—to meet audit standards.
• Site of Service: Usually office (POS 11), but telehealth might qualify under certain plans.
• Reimbursement: Varies by plan and location, but expect around $150–$250 for the service.

No major 2025 policy shifts noted, but always pull the latest from your BCBS provider manual or portal for local nuances.

Common Denials for CPT 99397 and How to Resolve Them

Denials often hit for age mismatches (e.g., billed for under-65s), frequency exceeds, or bundling with other visits. If you see CO-236 (not paid separately) or a frequency denial, it's fixable.

Resolution steps:

1. Check the EOB: Identify the code (e.g., duplicate or not typical for age).
2. Gather Proof: Pull notes showing preventive nature, patient age, and no overlap with problem-oriented care.
3. Appeal Quickly: Use the BCBS portal or form—submit within 180 days with a note like: "Appeal CPT 99397 denial; service is preventive reevaluation for established patient 68 years old, per guidelines."
4. Follow Up: Track via provider services line.

Many appeals succeed when documentation clearly shows the service as preventive.

Preventing BCBS CPT 99397 Denials in Family Medicine

Stay ahead by automating eligibility checks pre-visit to confirm coverage and last preventive date. Use EHR templates for consistent notes, and flag 99397 claims for a quick scrub before submission. Quarterly team reviews of BCBS updates can catch plan-specific rules early.

Practices with built-in coding alerts report fewer surprises and higher first-pass rates.

Ready to Simplify BCBS Preventive Billing?

Getting CPT 99397 right means more focus on patients and less on paperwork. Athelas RCM handles family medicine billing with AI that flags preventive code risks, automates appeals, and integrates seamlessly with your EHR—boosting clean claims without extra hassle.

Book a 15-minute demo to see how we can streamline your BCBS reimbursements.

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