Does G0397 require prior authorization?

No, G0397 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for G0397?

Medicare facility rate: $55.11. Non-facility rate: $67.47. Work RVU: 1.30.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.30

Facility

$55.11

Non-Facility

$67.47

All ICD-10, CPT and HCPCS codes billed for a preventive service should follow standard coding guidelines and be reported with diagnosis and procedure codes that identify the services as preventive and not for treatment of injury or illness.
Preventive services must be submitted with a designated wellness diagnosis code or maternity diagnosis code in the primary position where indicated (select the appropriate Designated Wellness Code from the pertinent Code Group).
Precertification documentation may be required when reasonable medical management techniques are applied; providers must follow plan-specific precertification processes when required.
For items that require a prescription (e.g., hospital-grade breast pump E0604; certain blood pressure monitors A4660/A4663/A4670), the order/prescription must be present and the item must be ordered through an in-network provider as specified.

Preventive care services designated by the Affordable Care Act (ACA) and ACA-designated resources (USPSTF grade A or B recommendations; ACIP recommendations adopted by CDC Director; HRSA-supported comprehensive guidelines such as Bright Futures, Uniform Panel of Secretary's Advisory Committee on Heritable Disorders in Newborns and Children, HRSA Women's Preventive Services Guidelines).
Wellness examinations (preventive medicine comprehensive E/M services) for well-baby, well-child, well-adult and well-woman visits (CPT codes 99381-99387, 99391-99397, 99461; HCPCS G0402, G0438, G0439, S0610, S0612, S0613).
Age-specific well visit frequencies: ages 0 to 5 per AAP Bright Futures; ages 5 and above annual wellness exam; additional visits for women's contraception management.
Administration/interpretation of health risk assessment instruments (e.g., suicide risk assessment; sudden cardiac arrest/death risk assessment) (96160, 96161).
Autism screening (as part of preventive services).
Anxiety screening for adults, children and adolescents, including pregnant and postpartum persons (96127, 96161).

CIGNA-A004 — Preventive Care Services - (A004)

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