Understanding the Age Range for CPT Code 99396
CPT code 99396 is specifically for a comprehensive preventive medicine evaluation of an established patient between 40 and 64 years old. An established patient has received services from the same physician or specialty within the last three years. This code is distinct from codes for new patients or other age groups. For adults aged 40-64, preventive care focuses on identifying and reducing risks for common conditions in this age range, such as heart disease, certain cancers, and diabetes. The visit provides a thorough health overview.
Services Included in a 99396 Visit
A comprehensive preventive visit billed under CPT code 99396 includes several key components for proactive health management. The visit typically lasts 30-45 minutes and covers:
- Comprehensive medical, family, and social history.
- Comprehensive physical examination, including vital signs and body systems assessment.
- Counseling on lifestyle, diet, exercise, and mental health.
- Risk factor reduction interventions.
- Ordering of appropriate diagnostic procedures and screenings.
- Development or update of a personalized preventive care plan.
Comparison with Other CPT Preventive Medicine Codes
CPT code 99396 is part of a series of codes (99391-99397) for established patient preventive visits, each for a specific age group.
| CPT Code | Age Range (Established Patient) | Common Purpose |
|---|---|---|
| 99391 | Younger than 1 year | Infant preventive visit |
| 99392 | 1-4 years | Early childhood preventive visit |
| 99393 | 5-11 years | Late childhood preventive visit |
| 99394 | 12-17 years | Adolescent preventive visit |
| 99395 | 18-39 years | Adult preventive visit |
| 99396 | 40-64 years | Comprehensive adult preventive visit |
| 99397 | 65 years and older | Senior preventive visit |
What to Document for a 99396 Visit
Accurate documentation is crucial for proper coding and reimbursement. Key documentation includes:
- Comprehensive History: Detailed notes on medical, family, and social history.
- Physical Exam: Record all parts of the physical examination and vital signs.
- Counseling: Document topics discussed regarding lifestyle and risk reduction.
- Procedures Ordered: List diagnostic tests and screenings ordered.
- Time Spent: Note time for complex cases (typically 30-45 minutes).
Billing Considerations for 99396
Billing for preventive services requires attention to detail, especially when addressing multiple health concerns.
- Use Modifier 25: For a separate E/M service on the same day, use modifier 25 on the problem-focused code.
- Payer Guidelines: Coverage varies by insurer. Traditional Medicare uses HCPCS codes (G0438, G0439) for Annual Wellness Visits, not 99381-99397.
- Diagnosis Codes: Link the preventive visit to a preventive diagnosis code (e.g., Z00 series) and problem visits to specific diagnosis codes.
For more information on coding, consult resources like the official CPT codebook or the American Academy of Family Physicians.
Conclusion: Ensuring Accurate Preventive Care for Adults
Using CPT code 99396 correctly is vital for providing and properly billing preventive care for established patients aged 40 to 64. Comprehensive evaluations, appropriate screenings, and thorough documentation are key to meeting billing requirements and providing quality care. Understanding this code and others in the preventive care suite helps navigate billing complexities and improve patient outcomes. Always verify payer-specific guidelines.
