Can 99395 and 99213 be billed together?

Yes, you can bill CPT code 99213 and CPT code 99395 together if the provider performs a significant, separately identifiable evaluation and management (E/M) service alongside a routine preventive visit.

Requirements for Billing Together

• Separate Problem: The patient must present with a distinct acute or chronic issue that requires separate evaluation, diagnosis, and management beyond the standard preventive exam.
• Modifier 25: You must append Modifier 25 to code 99213 to indicate that the problem-oriented service is distinct from the routine wellness check.
• Distinct Documentation: The medical record must clearly separate the documentation for both services, showing distinct history, exam, or medical decision-making for the sick/problem visit.
• Different Diagnosis Codes: Each CPT code must link to its correct, specific diagnosis. Assign a preventive code (such as the Z00 series) to 99395 and the specific symptom or condition code to 99213.

Yes, an office visit (problem-focused Evaluation and Management, or E/M service) and a preventive visit can be billed together on the same day if the provider addresses a significant, separately identifiable medical problem.

Billing and Coding Rules

• Separate Need: The additional problem or abnormality must require extra work, medical decision-making, or distinct evaluation beyond the routine preventive exam. Minor or trivial issues (like a quick question or simple prescription refill without changes) do not qualify.
• Modifier 25: You must append Modifier 25 to the office visit E/M code (such as CPT 99212–99215) to show that a distinct, separate service was provided alongside the preventive code.
• Documentation: The medical record must clearly document the separate history, evaluation, and decision-making for the acute or chronic problem.

Insurance and Patient Costs

• Coverage: Both Medicare and major commercial insurance allow dual billing when criteria are met, though specific rules can vary by payer.
• Out-of-Pocket Costs: While routine preventive visits are often fully covered with no copay under insurance plans, adding a separate problem-focused office visit may trigger an additional copay, coinsurance, or deductible charge for the patient.

CPT code 99395 can generally be billed once per 12-month period (or once a year) per patient for commercial and ACA marketplace insurance plans.

Billing Frequency Details

• Time Window: Most insurance systems use an 11-to-13-month window (rather than a strict 365-day count) to allow for regular scheduling changes.
• Duplicate Claims: Billing 99395 a second time within that 12-month window will usually be rejected by insurers as a duplicate service.
• Additional Visits: If a patient needs another visit within the same year for a specific health issue, use a problem-oriented evaluation and management (E/M) code (like 99212–99215) instead of another preventive code.
• Medicare Exclusions: Code 99395 is excluded by Medicare; Medicare uses specific HCPCS codes like G0438 or G0439 for annual wellness visits.

Medicare billing guidelines for Annual Wellness Visits (AWVs) center on specific HCPCS codes, timing rules, and documentation requirements to ensure full coverage without patient cost-sharing.

Key Billing Codes

• G0438: Initial Annual Wellness Visit, available once per lifetime for a beneficiary after their first 12 months of Part B enrollment (if they have not billed an Initial Preventive Physical Examination or IPPE within that window).
• G0439: Subsequent Annual Wellness Visit, billed yearly thereafter (at least 11 full calendar months after the previous initial or subsequent AWV).
• G0402: Initial Preventive Physical Examination ("Welcome to Medicare" physical), a separate one-time visit restricted to the first 12 months of enrollment.

Core Billing Rules

• Frequency limits: You cannot bill G0438 or G0439 within 12 months of billing G0402 for the same patient.
• Cost-sharing: Medicare Part B covers AWVs at 100% with zero deductible or coinsurance when performed as a standalone preventive service.
• Simultaneous E/M visits: If you provide a significant, separately identifiable medically necessary Evaluation and Management (E/M) service (codes 99202–99215) on the same day, report the additional code with modifier 25. Patient cost-sharing will apply to the E/M portion only.
• Required documentation: Claims require a valid NPI, place of service, date of service, and appropriate ICD-10 diagnosis code (such as Z00.00 for normal findings or Z00.01 if abnormalities are found).

The primary difference between CPT code 99395 and CPT code 99396 is the age range of the established patient receiving the periodic preventive medicine evaluation.

Age and Description Differences

• CPT 99395: Used for an established patient aged 18 to 39 years.
• CPT 99396: Used for an established patient aged 40 to 64 years.

Shared Features

• Patient Status: Both codes apply to established patients (someone who has received professional services from the physician or another provider in the same specialty/group practice within the past three years).
• Service Type: Both report a periodic, comprehensive preventive wellness examination, which includes age- and gender-appropriate history, physical examination, counseling/anticipatory guidance, risk factor reduction, and ordering of routine labs or diagnostics.
• Selection Criteria: Neither code is based on time spent or the complexity of medical decision-making; they are chosen strictly based on the patient's age on the date of service and their established status.