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CPT code 99395 represents a periodic comprehensive preventive medicine reevaluation and management service for an established patient aged 18–39. It is one of the most frequently billed CPT codes in preventive medicine, accounting for a significant portion of preventive service claims. According to Definitive Healthcare, in 2024, CPT code 99395 was the second most common preventive medicine procedure, comprising 12.14% of all such procedures. Its high usage reflects the emphasis on preventive care in this age group, a critical period for establishing healthy habits and identifying potential health risks early. These visits focus on health maintenance, risk factor reduction, and anticipatory guidance rather than treating acute or chronic illnesses.
CPT code 99395 is for established patients, while CPT code 99385 is for new patients. An established patient has received professional services from the physician or another physician of the same specialty in the same group practice within the past three years. A new patient has not. Both codes apply to the 18–39 age group and cover similar comprehensive preventive services. Choosing the correct code based on patient history is critical to ensure accurate billing and avoid claim denials.
A 99395 preventive visit is comprehensive and tailored to the patient’s age and gender. Services typically include:
Yes, a problem-oriented Evaluation and Management (E/M) service can be billed alongside a 99395 visit if a significant, separately identifiable issue is addressed that requires additional work beyond the preventive service. Use an appropriate office/outpatient E/M code (99202–99215) with modifier 25 appended to indicate it is distinct from the preventive visit. Clear, detailed documentation is essential to justify medical necessity for both services and prevent claim denials.
CPT code 99395 is typically billed for an annual preventive visit. Most insurance plans, including those under the Affordable Care Act (ACA), cover one preventive visit per year. However, the definition of a “year” varies by payer—some use a calendar year, others a rolling 12-month period. Verify patient eligibility and payer policies before rendering the service to avoid denials and ensure patient satisfaction.
Common reasons for 99395 claim denials include:
Robust documentation, patient eligibility verification, and accurate coding are key to avoiding these issues.
AI scribes streamline documentation by generating comprehensive, accurate clinical notes based on clinician-patient interactions. They ensure all required components of a 99395 visit—history, exam, counseling, and anticipatory guidance—are thoroughly documented. By automating this process, AI scribes reduce administrative burden, allowing clinicians to focus on patient care and improving billing accuracy for preventive services.
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How do I correctly bill for an acute problem like a URI that is addressed during a scheduled 99395 preventive exam?
When you address a significant, separately identifiable acute issue like a URI during a preventive visit, you can bill for both services. To do this correctly, you must append Modifier 25 to the problem-oriented Evaluation and Management (E/M) code (e.g., 99213 or 99214). Your documentation must clearly distinguish the work performed for the preventive service from the work performed for the acute problem. Think of it as telling two separate stories in your note: one for the comprehensive preventive care and another for the history, exam, and medical decision-making related to the acute illness. Consider implementing AI scribe technology to automatically parse the conversation and generate distinctly separate documentation for both the preventive and problem-oriented components of the visit, ensuring compliance and accurate billing.
What specific lab tests or procedures can be ordered during a 99395 visit, and are they billed separately from the preventive service itself?
During a 99395 visit, ordering age and gender-appropriate laboratory and diagnostic procedures is an included component of the service. However, the actual performance of these tests is billed separately. For example, you would bill 99395 for the comprehensive preventive evaluation, and then also bill for the specific CPT codes for services like a lipid panel, a Pap smear collection (Q0091 for Medicare) and the lab's analysis, or any immunizations administered. It is crucial to link the appropriate diagnosis codes to each service to differentiate between routine screening and problem-oriented testing. Explore how integrated billing platforms can help automate the process of linking the correct diagnostic and procedural codes to avoid claim denials.
What is the exact difference between CPT 99395 for an established patient and 99385 for a new patient, especially if they haven't been to our clinic in a while?
The key difference lies in the CPT definition of an "established patient." A patient is considered established if they have received any professional face-to-face service from you or another physician of the exact same specialty and subspecialty within your group practice within the last three years. If the patient (or another physician in your group) has not rendered a service in that 36-month period, they are considered a "new patient," and you must use CPT code 99385. This "three-year rule" is strict. Before a visit, it's a best practice to have your front office staff verify the date of the patient's last encounter to ensure the correct code is selected from the start. Learn more about how practice management software can automatically flag patients as new or established to prevent these common coding errors.