Decoding CPT Code 99396
CPT code 99396 is a medical billing code used for a comprehensive preventive medicine evaluation and management service. It applies to established patients aged 40 to 64. An 'established patient' is someone who has received professional services from a provider in the same group and specialty within the last three years. This code focuses on proactive health management for middle-aged adults.
What the preventive visit includes
The services covered by CPT code 99396 typically include a review of medical history, a physical examination, counseling, and ordering necessary tests. These services are tailored to the patient's age and gender.
Age-Appropriate Screenings and Counseling
For the 40-64 age group, the exam includes screenings and discussions relevant to this life stage, such as cardiovascular risks and certain cancers. Counseling often covers areas like diet, exercise, smoking, and stress.
How CPT 99396 Compares to Other Codes
The specific CPT code used for a preventive visit depends on the patient's age and whether they are a new or established patient.
| CPT Code | Patient Status | Age Group | Covered Services |
|---|---|---|---|
| 99395 | Established | 18-39 years | General preventive E/M |
| 99396 | Established | 40-64 years | Comprehensive preventive E/M with age-specific focus |
| 99397 | Established | 65+ years | Comprehensive preventive E/M for older adults |
| 99385 | New | 18-39 years | Initial comprehensive preventive E/M for a new patient |
| 99386 | New | 40-64 years | Initial comprehensive preventive E/M for a new patient |
| 99387 | New | 65+ years | Initial comprehensive preventive E/M for a new patient |
The Important Distinction from a "Sick Visit"
A preventive visit (99396) focuses on health maintenance, unlike a "sick visit" which addresses specific health problems. If a provider manages a new or existing problem during a preventive exam, an additional E/M code might be billed with Modifier 25, indicating a separate service was provided.
Medicare vs. Private Insurance: The Coding Difference
Medicare does not use CPT code 99396. Instead, it uses HCPCS G-codes for annual wellness visits (AWVs). The "Welcome to Medicare" visit (G0402) is a one-time visit, while subsequent AWVs use codes like G0438 and G0439. Medicare AWVs focus on prevention plans and risk assessment but may not include a full physical exam like a CPT 99396 visit. Patients should confirm coverage with their insurer.
Maximizing Your Annual Checkup: What Patients Can Do
An annual checkup is vital for healthy aging in the 40-64 age range. Patients can enhance their visit through preparation.
Preparing for Your Visit
- Bring Information: Have a list of medications and supplements, plus an updated family health history.
- Prepare Questions: Write down any health concerns or questions about wellness goals.
- Confirm Coverage: Check with your insurer about preventive care coverage to understand potential costs for diagnostic services.
- Communicate: State the visit is for a preventive exam. If discussing a separate issue, inform your provider to ensure correct billing with Modifier 25.
For more on preventive service billing, consult the {Link: AAFP Guide to Preventive Coding https://www.aafp.org/pubs/fpm/blogs/gettingpaid/entry/avoiding_mistakes_preventive_coding.html}.
Conclusion
CPT code 99396 is used for preventive care in established patients aged 40-64. It covers exams, screenings, and counseling to promote health and prevent disease. Understanding this code helps patients actively manage their health.
