Routine Physical Exams: Statutory Denials
Denial Reason, Reason and Remark Code
With a valid Advance Beneficiary Notice (ABN):
- PR-204: This service, equipment and/or drug is not covered under the patient's current benefit plan
- PR-N130: Consult plan benefit documents/guidelines for information about restrictions for this service
Without a valid ABN:
- CO-204: This service, equipment and/or drug is not covered under the patient's current benefit plan
- CO-N130: Consult plan benefit documents/guidelines for information about restrictions for this service
CPT code: 99397 (Status "N" on MPFSDB)
Resolution and Resources
- Routine physical exams are never covered by Medicare except under the "welcome to Medicare physical" or "initial preventive physical exam" (IPPE) guidelines. For more information on the IPPE, refer to the CMS website for preventive services:
- The Centers for Medicare & Medicaid Services (CMS) does not require providers to submit claims for services that are excluded by statute under Section 1862(a) (1) of the Social Security Act. However, if the patient (or his/her representative) believes that a service may be covered and asks that a claim be submitted or desires a formal Medicare determination, you must file a claim for that service to effectuate the patient's right to a determination.
Notice of Exclusion from Medicare Benefits Information
If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets you know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
- CMS has developed new Advance Beneficiary Notice (ABN) forms. The new forms incorporate the old Notice of Exclusion from Medicare Benefits (NEMB) language. Use of the revised ABN is optional for services that are excluded from Medicare benefits. Access the revised ABN and other background information from the CMS website.
- If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GY. Refer to the Palmetto GBA Modifier Lookup tool (located under Self Service Tools on the Palmetto GBA Web page) for information on HCPCS modifier GY or GA.