A preventive visit pays for the exam the patient scheduled. The problem they mention while the blood pressure cuff is on does not fit that code, and folding it into the physical gives away work already done. Adding the problem visit without its own note loses the payment at review.
What this covers
- Preventive codes 99381 to 99397 are selected by patient age and by new or established status.
- Medicare pays G0402, G0438 and G0439 for those visits instead of the preventive codes.
- A problem needing its own history, exam and decision making bills separately with modifier 25.
- Modifier 33 marks a commercial service as preventive; Medicare uses modifier PT instead.
- Vaccines split between Part B and Part D, and Medicare pays Part B administration with G codes.
What Medicare covers when a patient asks for a physical
Routine physical checkups are excluded from Medicare by regulation: exams performed for a purpose other than treatment or diagnosis of a specific illness, symptom, complaint or injury. Congress added preventive exceptions over four decades, each with its own code. G0402 pays one initial preventive physical exam per lifetime, in the first 12 months of Part B coverage. G0438 covers a first annual wellness visit and G0439 each one after.
A CMS change request instructs providers not to bill CPT codes 99381 to 99397 for those visits, because Medicare pays the G codes. Deductible and coinsurance are waived when the provider accepts assignment, and the next visit is not payable until at least 11 months after the month of the prior one. Family medicine practices decide this before the visit.
The wellness visit centers on a health risk assessment, an updated history, a written screening schedule and personalized referrals, and laboratory tests are not part of it. The IPPE adds height, weight, body mass index, blood pressure and a visual acuity screen.
The preventive codes, and the age band inside each one
Outside Medicare, the annual physical comes from the preventive medicine section of CPT: 99381 to 99387 for new patients, 99391 to 99397 for established, with the final digit tracking age.
| Patient age | New patient | Established patient |
|---|---|---|
| Under 1 year | 99381 | 99391 |
| 1 through 4 | 99382 | 99392 |
| 5 through 11 | 99383 | 99393 |
| 12 through 17 | 99384 | 99394 |
| 18 through 39 | 99385 | 99395 |
| 40 through 64 | 99386 | 99396 |
| 65 and older | 99387 | 99397 |
Each code stands for a comprehensive preventive service: an age and gender appropriate exam, counseling, risk factor reduction, and the orders that come out of the visit. Stable chronic conditions belong inside it, and counseling outside the exam is reported separately, including 99406 or 99407.
Z00.00 covers a general adult exam with no abnormal findings and Z00.01 the same exam when something abnormal turns up, with an added code naming the finding. Children use Z00.129 or Z00.121, immunizations take Z23, and screenings take a Z12 or Z13 code. A screening lab ordered for a symptom is diagnostic instead, and medical coding teams see that at order entry.
Modifier 25 when a problem surfaces during the physical
Modifier 25 tells a payer that an office or outpatient visit was significant and separately identifiable from another service the same day. With a preventive visit it goes on the problem-oriented E/M code, and the preventive code stays clean: 99396 for the physical, plus an E/M visit with modifier 25 for the new problem.
The threshold is real work. CPT asks whether the problem required additional work to perform the key components of a problem-oriented E/M service. A stable condition already in the chart does not meet it.
A combined note is the most common reason a modifier 25 claim comes back or recoups. The clearest chart has a preventive note that ends and a problem note that begins, each with its own history, exam and plan.
- The problem in the patient’s own words, in a note separate from the wellness documentation
- A problem-oriented history, exam and decision making with its own plan
- An E/M level that matches that note
- Modifier 25 on the E/M line only, never on the preventive code
Some payers discount the second service. Healthfirst pays the problem-oriented E/M at 50 percent of the contracted allowable when modifier 25 is supported, because overlapping components already sit inside the preventive service. Medicare’s G2211 add-on was denied whenever the base E/M carried modifier 25 until CMS changed the policy for dates of service from January 1, 2025, when the same-day service is a wellness visit or vaccine administration.
Modifiers 33, PT and KX do three different jobs
| Modifier | Where it applies | What it tells the payer |
|---|---|---|
| 33 | Commercial ACA benefits, plus specific Medicare instructions | The service was furnished as prevention, so the plan waives cost sharing |
| PT | Medicare | A screening colonoscopy became diagnostic or therapeutic |
| KX | Medicare | A screening colonoscopy followed a positive stool or blood test, keeping both tests free |
Modifier 33 works on codes that could go either way: a colonoscopy, a lipid panel, a cessation session. The CPT definition ties it to a service delivered under a US Preventive Services Task Force A or B rating or another preventive mandate. Appending it to a service furnished for an established illness does not convert it.
Medicare does not need modifier 33 to recognize most preventive services. It has dedicated screening codes that MACs pay without cost sharing. One instruction does: advance care planning, 99497 and 99498, billed on the same claim as a wellness visit with modifier 33, waives the deductible and coinsurance once a year.
Vaccines at the physical: product, administration, and who pays
Congress added preventive vaccines to Part B one at a time: pneumococcal in 1981, hepatitis B for patients at medium or high risk in 1984, influenza in 1993, and COVID-19 in 2020. Shingles, Tdap and RSV sit under Part D.
| Vaccine | Benefit | Medicare administration code |
|---|---|---|
| Influenza | Part B | G0008 |
| Pneumococcal | Part B | G0009 |
| Hepatitis B, intermediate or high risk | Part B | G0010 |
| COVID-19 | Part B | 90480 |
| Shingles, Tdap, RSV and other ACIP adult vaccines | Part D | Pharmacy benefit, so give the patient a claim form |
Medicare waives the deductible and coinsurance on the four Part B vaccines and their administration, and pays two administration fees when a patient receives two of them the same day. That treatment reached hepatitis B on January 1, 2025, and Part D vaccines have carried no cost sharing since January 1, 2023, for ACIP-recommended adult vaccines.
Medicare does not pay 90471 or 90472 for its Part B preventive vaccines. Those lines deny and the charge becomes practice liability. Bill the administration code matching the vaccine on its own line, and add the ordering physician’s name and NPI on hepatitis B claims.
Commercial and Medicaid claims use the administration codes directly. 90460 pays the first or only component of each vaccine through age 18 when the physician or another qualified health professional counsels face to face, and 90461 each additional component of a combination vaccine. Without documented counseling, or over age 18, administration runs 90471 and 90472.
Screening rules that keep a service preventive
Medicare publishes a frequency for each covered screening and edits claims against history, so the eligibility check belongs before the order.
| Screening | Medicare code | Frequency |
|---|---|---|
| Screening mammography | G0202 | Every 12 months for women 40 and older, plus one baseline at 35 to 39 |
| Colorectal, average risk | G0121 | Every 10 years, from age 45 |
| Colorectal, high risk | G0105 | Every 24 months |
| Lung cancer screening with low dose CT | 71271, counseling at G0296 | Annually, ages 50 to 77, with 20 pack years and current or recent smoking |
The colonoscopy is the screening that changes character mid-encounter. A polyp found and removed turns it into a therapeutic service, and the patient’s cost sharing returns unless the claim says otherwise. Section 122 of the Consolidated Appropriations Act of 2021 set the phase-down.
With modifier PT on at least one code, Medicare waives the deductible and applies a reduced coinsurance: 15 percent in 2023 through 2026, 10 percent in 2027 through 2029, and none from January 1, 2030. That reduction covers every procedure billed on the claim.
A screening colonoscopy after a positive stool or blood test is a screening test in its own right. Report KX and Medicare waives cost sharing on both, a rule that reached blood-based tests in 2025. Medicare also sets its own screening intervals, paying annual mammography from 40 where the task force stops at 74, a difference internal medicine practices see monthly.
Questions about annual physical coding
Yes, when the problem requires work beyond the preventive service. Report the preventive code for the physical and an office or outpatient E/M code with modifier 25 for the problem, in separate notes.
Medicare excludes routine physical checkups, so it does not pay preventive codes 99381 to 99397 for a wellness visit. It pays G0402 for one initial preventive physical exam in the first 12 months of Part B coverage, G0438 for the first wellness visit, and G0439 for every one after.
On the problem-oriented office or outpatient E/M code, not on the preventive medicine code. The preventive service is reported clean, and the modifier tells the payer that the problem visit was significant and separately identifiable from the physical that day.
Once every 12 months. The count runs from the month after the previous IPPE or wellness visit, so at least 11 months have to pass before the next one is payable.
Medicare Part B pays influenza vaccine administration with G0008 rather than 90471. Its four Part B preventive vaccines use G0008, G0009, G0010 and 90480 for influenza, pneumococcal, hepatitis B and COVID-19. A line with 90471 denies and the charge becomes practice liability.
Z00.00 for a general adult exam with no abnormal findings, or Z00.01 when something abnormal turns up, with an additional code naming the finding. Children use Z00.129 or Z00.121, and screening tests take a Z12 or Z13 code.
The bottom line
An annual physical is one visit with a preventive service inside it and, often, a problem that deserves its own note. The codes are settled: age bands for the preventive service, modifier 25 for the problem, modifier 33 or PT when a payer must know a service stayed preventive, and each payer’s frequency and administration rules.
How much of the annual physical is going unbilled?
We code and bill preventive visits for primary care practices, including same-day problem visits, vaccine administration and the screening rules that decide what a patient owes. Send us one month of claims and we will show you where preventive revenue was written off.
Request a free preventive coding auditThis article describes general coding and billing practice rather than a coverage determination; confirm current requirements with each payer’s policy and provider manual.
