CMS Pub. 100-04, ch. 12, § 30.6.2

Preventive Medicine Service

(Rev. 12546; Issued: 03-14-24; Effective: 05-15-24; Implementation: 05-15-24)

See Chapter 18 for payment for covered preventive services.

When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the

same occasion as a noncovered preventive medicine service (CPT codes 99381-99397),

consider the covered visit to be provided in lieu of a part of the preventive medicine service of

equal value to the visit. A preventive medicine service (CPT codes 99381-99397) is a

noncovered service. The physician may charge the beneficiary, as a charge for the noncovered

remainder of the service, the amount by which the physician’s current established charge for

the preventive medicine service exceeds his/her current established charge for the covered

visit. Pay for the covered visit based on the lesser of the fee schedule amount or the

physician’s actual charge for the visit. The physician is not required to give the beneficiary

written advance notice of noncoverage (ABN) of the part of the visit that constitutes a routine

preventive visit. However, in accordance with Pub.100-04, Chapter 50, section 50.2.1,

physicians are strongly encouraged to provide an ABN to beneficiaries when providing and

billing for a preventive medicine service (CPT codes 99381-99397).

Also, the physician is responsible for notifying the patient in advance of his/her liability for the

charges for services that are not medically necessary to treat the illness or injury.

There could be covered and noncovered procedures performed during this encounter (e.g.,

screening x-ray, EKG, lab tests.). These are considered individually. Those procedures which

are for screening for asymptomatic conditions are considered noncovered and, therefore, no

payment is made. Those procedures ordered to diagnose or monitor a symptom, medical

condition, or treatment are evaluated for medical necessity and, if covered, are paid.