CPT code 99396 specifically represents a comprehensive preventive medicine evaluation for established patients between the ages of 40 and 64. 

This guide provides guidance on CPT code 99396, covering its definition, billing requirements, comparison with related codes, costs, insurance coverage, common issues, and strategies for maximizing its proper utilization in clinical practice.

What Is CPT Code 99396?

CPT code 99396 designates a comprehensive preventive medicine evaluation and management service for an established patient who is between 40 and 64 years of age.

Unlike problem-oriented visits, this code encompasses a thorough age and gender-appropriate history, examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of appropriate laboratory and diagnostic procedures.

The preventive medicine service represented by this code focuses on health maintenance rather than addressing specific symptoms or conditions.

It typically includes a complete review of the patient's medical, family, and social history, a comprehensive physical examination, and counseling about age-appropriate preventive health measures such as screenings, immunizations, and lifestyle modifications to reduce health risks.

Components of a 99396 service include:

• Comprehensive age and gender-appropriate history

• Comprehensive physical examination

• Counseling and risk factor reduction interventions

• Ordering of laboratory/diagnostic procedures

• Documentation of preventive health recommendations

• Development or update of a preventive care plan

Who Can Bill CPT 99396?

Several healthcare professionals are qualified to bill for CPT code 99396, provided they meet the specific requirements for delivering comprehensive preventive medicine services:

Licensed medical professionals who can bill this code include:

• Physicians (MDs and DOs)

• Nurse Practitioners

• Physician Assistants

• Some states may allow other advanced practice providers with appropriate supervision

Settings where CPT code 99396 can be billed include:

• Private medical practices

• Hospital-owned outpatient clinics

• Community health centers

• Multi-specialty group practices

• Academic medical centers

• Some urgent care facilities that provide preventive services

Requirements for billing this code typically include:

• Provider must be credentialed with the patient's insurance

• Service must be delivered face-to-face

• Documentation must support the comprehensive nature of the visit

• Medical record must reflect all components of preventive service

• The patient must be established (not new) to the practice (within the past 3 years)

CPT 99396 vs. Related Codes

CPT 99396 is part of a family of preventive medicine service codes, each designed for specific patient populations or circumstances. Understanding the differences helps ensure accurate coding and appropriate reimbursement.

The primary differences between 99396 and related codes include:

Preventive Medicine for Different Age Groups:

• 99381-99387: New patient preventive medicine services

• 99391-99397: Established patient preventive medicine services

• 99395: Ages 18-39 (vs. 99396 for ages 40-64)

• 99397: Ages 65 and older (vs. 99396 for ages 40-64)

Problem-Oriented vs. Preventive Services:

• 99201-99215: Problem-oriented office visits focused on specific complaints or conditions

• 99396: Comprehensive preventive service not triggered by symptoms

When to use each:

• Use 99396 when providing a complete preventive service to an established patient aged 40-64

• Use 99395 or 99397 if the patient falls into those age ranges instead

• Use problem-oriented visit codes (99202-99215) when addressing specific complaints

• Consider using both preventive and problem-oriented codes with a modifier when both services are provided in the same visit

When a preventive visit and problem-oriented service occur during the same encounter, providers can bill both codes with an appropriate modifier (typically modifier -25 on the problem-oriented code), provided documentation supports both services.

Cost of CPT 99396

The cost of a preventive medicine service billed under CPT 99396 varies based on multiple factors, including geographic location, practice setting, and provider specialty. Shared below are average rates, but these can be highly variable depending on several factors.

Understanding these costs helps providers set appropriate fees and helps patients anticipate potential expenses.

Without insurance coverage, patients might expect to pay:

• Average range: $200-$350 for the preventive visit alone

• Rural areas typically charge: $150-$250

• Urban areas typically charge: $250-$400

• Additional costs apply for laboratory tests, immunizations, or screenings

Factors affecting the cost include:

• Geographic location (higher costs in metropolitan areas)

• Provider specialty and experience

• Practice overhead costs

• Facility type (hospital-based practices often charge more)

• Additional services performed during the visit

• Local market competition

With insurance coverage, patient costs typically include:

• Under the Affordable Care Act (ACA), most preventive services are covered at 100% with no copay

• Medicare Part B covers one Annual Wellness Visit at 100% (slightly different from 99396)

• Some grandfathered plans may require copays of $20-$50

• Non-covered preventive services may be the patient's responsibility

Insurance Coverage

Most health insurance plans provide coverage for preventive medicine services like those billed under CPT 99396, though coverage details vary by plan and insurer.

Major insurance providers typically covering preventive services include:

• Private insurance carriers (Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare)

• Medicare (through Annual Wellness Visit benefits)

• Medicaid

• TRICARE

• Most Marketplace plans under the ACA

Steps patients should take to verify coverage:

• Contact their insurance provider directly

• Review their Summary of Benefits and Coverage document

• Check if their provider is in-network

• Inquire about frequency limitations (most plans cover one preventive visit annually)

• Ask about coverage for additional services ordered during the preventive visit

For providers, it's important to:

• Verify insurance benefits before the visit

• Clearly explain to patients what services are preventive versus diagnostic

• Obtain necessary prior authorizations when required

• Document services meticulously to support claims

• Submit claims with appropriate diagnosis codes that support preventive services

Common Issues or Problems with CPT Code 99396

Despite being a standard code, providers and billing staff often encounter challenges when billing CPT 99396. Awareness of these issues and their solutions helps ensure proper reimbursement and compliance.

Claim Denials and Their Solutions

Frequent reasons for denials include:

• Frequency limitations: Most plans cover preventive services once per calendar year or every 12 months

  • Solution: Verify last preventive service date before scheduling

• Incorrect patient status: Using established patient code for a new patient

  • Solution: Verify patient status and use appropriate new (99386) or established (99396) patient code

• Insufficient documentation: Not documenting all required elements

  • Solution: Implement comprehensive preventive visit templates in the EHR

• Incorrect diagnosis codes: Using problem-oriented rather than preventive Z-codes

  • Solution: Use appropriate Z00.00 or Z00.01 codes for general adult examinations

Addressing These Challenges

Providers can minimize issues by:

• Establishing clear protocols for scheduling preventive visits

• Implementing preventive service documentation templates

• Training staff on preventive service billing requirements

• Conducting regular audits of preventive service documentation

• Developing patient education materials about preventive services

Mistakes to Avoid With CPT Code 99396

Several common mistakes can lead to claim denials, audit risks, or reduced reimbursement when billing CPT 99396. Understanding these pitfalls helps providers maintain compliance and optimize revenue.

Documentation Deficiencies

Inadequate documentation represents one of the most significant risks when billing preventive services:

• Missing elements of a comprehensive history or exam

• Lack of age-appropriate counseling documentation

• Failure to document risk factor reduction interventions

• Incomplete preventive care plans

• Missing screening recommendations

To avoid these mistakes:

• Use comprehensive preventive visit templates

• Document all counseling topics and time spent

• Include all health risk assessments performed

• Clearly record recommended screenings and preventive measures

• Document patient education provided

Coding and Billing Errors

Improper coding practices can lead to denials or compliance risks:

• Using preventive codes when visit was problem-focused

• Failing to append appropriate modifiers when billing problem-oriented and preventive services together

• Using incorrect age-based preventive codes

• Billing preventive services more frequently than allowed

• Missing opportunities to bill for additional separately payable services

Best practices include:

• Regular staff training on preventive service coding

• Creating clear workflows, distinguishing preventive from problem-oriented visits

• Implementing coding validation checks before claim submission

• Developing tools to track preventive service dates for each patient

• Establishing protocols for handling "dual-purpose" visits

Service Delivery Issues

Problems in service delivery can affect both reimbursement and quality of care:

• Not performing all required elements of a comprehensive preventive service

• Rushing through preventive visits

• Focusing too much on existing problems during preventive visits

• Failing to provide age and gender-appropriate screenings

• Not addressing all recommended preventive measures

Improvement strategies include:

• Allocating adequate time for preventive visits (often 30-45 minutes)

• Using preventive care checklists based on age, gender, and risk factors

• Implementing pre-visit planning to identify needed preventive services

• Considering group visits for some preventive education components

• Utilizing support staff to complete appropriate components of the visit

Maximizing Benefit with Proper 99396 Billing

Strategic approaches to preventive service delivery and billing can optimize both patient care and practice revenue. Implementing these strategies helps ensure comprehensive preventive care while maintaining financial sustainability.

Workflow Optimization

Effective workflows enhance both clinical and financial outcomes:

• Schedule adequate time for comprehensive preventive visits (30-45 minutes)

• Use pre-visit planning to identify needed preventive services

• Implement patient pre-registration processes to verify insurance coverage

• Develop protocols for handling preventive and problem-oriented needs in the same visit

• Create clear documentation templates aligned with billing requirements

Recommended workflow improvements include:

• Sending preventive visit questionnaires before appointments

• Having patients complete health risk assessments prior to seeing the provider

• Utilizing support staff to gather initial history and vitals

• Implementing EHR tools that prompt for age-appropriate preventive services

• Creating patient education materials about preventive care

Documentation Strategies

Strong documentation supports both quality care and proper reimbursement:

• Document all components of history, examination, and counseling

• Clearly identify risk factors and interventions discussed

• Record specific preventive recommendations and their rationale

• Document patient education provided

• Include time spent when relevant for coding

Best documentation practices include:

• Using standardized templates with all required elements

• Documenting specifically what was counseled rather than using generic statements

• Recording normal findings as well as abnormal ones

• Documenting patient preferences and shared decision-making

• Including follow-up plans for recommended screenings or interventions

Patient Education and Engagement

Engaged patients are more likely to complete recommended preventive services:

• Educate patients about the value of regular preventive visits

• Provide clear explanations of insurance coverage for preventive services

• Develop recall systems for annual preventive visits

• Create preventive care plans that patients can reference

• Use patient portal tools to remind patients of needed services

Effective patient engagement strategies include:

• Providing visit summaries with clear preventive recommendations

• Developing educational materials about age-appropriate screenings

• Creating preventive care scorecards for patients

• Implementing reminder systems for scheduled preventive services

• Offering incentives for completing recommended preventive measures

Frequently Asked Questions

Can I bill a problem-oriented visit on the same day as CPT 99396?

Yes, you can bill a problem-oriented visit (99202-99215) on the same day as a preventive visit if the problem addressed is significant and separately identifiable from the preventive service. Use modifier -25 on the problem-oriented code and ensure documentation clearly supports both services. The medical record should distinctly outline the elements of the preventive service and separately document the history, examination, and medical decision-making related to the problem.

Does Medicare cover CPT code 99396?

Medicare does not specifically cover CPT 99396. Instead, Medicare covers the "Annual Wellness Visit" using codes G0438 (initial) and G0439 (subsequent), which are similar but not identical to commercial preventive visit codes. Additionally, Medicare covers the "Welcome to Medicare" preventive visit (G0402) once within the first 12 months of Medicare Part B enrollment. After this initial visit, providers should use code G0438 for the first Annual Wellness Visit (only if G0402 has not been billed in the past 12 months) and G0439 for subsequent visits.

For Medicare patients, providers should use these Medicare-specific codes rather than the 99396 CPT code.

What diagnosis codes should be used with CPT 99396?

The most appropriate primary diagnosis codes for preventive visits are from the Z00 series, typically Z00.00 (general adult medical examination without abnormal findings) or Z00.01 (general adult medical examination with abnormal findings). Additional Z codes can be used to indicate specific health states, risk factors, or family history that influenced the preventive service. Examples include Z13.6 (encounter for screening for cardiovascular disorders) or Z82.49 (family history of ischemic heart disease).

How often can CPT 99396 be billed for a patient?

Most insurance plans, including those governed by the Affordable Care Act, cover one comprehensive preventive visit per year. Some plans define this as once per calendar year, while others specify once every 12 months. Providers should verify specific frequency limitations with each payer. Billing preventive services more frequently than allowed by the patient's insurance will likely result in claim denial or patient financial responsibility for the service.

Bottom Line

CPT code 99396 represents a vital component of comprehensive healthcare for adults aged 40-64, focusing on prevention rather than treatment. By understanding the proper application, documentation requirements, and billing practices associated with this code, healthcare providers can deliver high-quality preventive care while ensuring appropriate reimbursement.

Healthcare providers should implement systems for delivering and documenting preventive services, ensuring that all components are addressed and properly recorded to support comprehensive patient care and compliant billing practices.

Disclaimer

This guide is intended for informational purposes only and does not constitute medical, legal, or financial advice. Healthcare providers should consult with their compliance officers, legal counsel, and individual payer policies to ensure adherence to current coding and billing regulations. Patients should verify their specific insurance coverage and benefits before receiving services. Coding and reimbursement regulations change frequently, and this information may not reflect the most current guidelines.